Position Purpose: Perform duties to conduct and manage the day to day operations of the utilization management functions to include denials. Communicate with departmental and plan administrative staff to facilitate daily operations of the utilization management functions.
Ensure compliance with established referral, pre-certification and authorization policies, procedures and processes
Facilitate ongoing communication between care management staff, utilization management staff and contracted providers.
Maintain compliance with URAC, federal and state regulations and contractual agreements, including HIPAA
Develop, implement and maintain compliance regarding medical utilization management and appeals functions
Monitor the effectiveness of existing outreach and intervention efforts
Ensure appropriate medical necessity review for all levels of care and assure appropriate knowledge, education, and interve
Valid through: 2020-4-8