$235K - $349K
Functional Role and Responsibilities:
Reviews and decides UM cases, ensuring that all requests for services and resources meet medical necessity criteria, and are medically prudent following decision hierarchy, evidence based appropriate use criteria and peer-reviewed guidelines.
Participates in peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.
Leverage the utilization management program detail, Health Plan information, and other evidence based tools to provide individualized analysis to providers and facilities and suggest program development or modification within medical management to improve member outcomes.
Will work closely with the VP of Compliance, Senior Directors of CM and UM, CM/UM staff, and leaders to mandatorily hold the MA programs within strict adherence to CMS regulations and compliance mandates and guidelines. Will assist in maint
Valid through: 2020-4-9