Interface with external agencies and representativesrelativeto the utilizationmanagement process, including health plans, medical providers, vendorsand CMS. 

Perform Utilization Review activities prospectively or post-service (retrospective) for elective/urgent hospital admissions and outpatient services as specified on the Prior Authorization List with complete andtimelyreports to members, providers and health plans as requested.

Assistmedical directors with benefit interpretation, obtain additionalmedical necessity information and research issues. Be available for case discussion as needed.

Works closely with physicians, other healthcare and service providers, health plan representatives, care managementstaffand partners with UM Coordinators to provide medical management for incoming authorization requests and specialist referrals using nationally recognized guidelines to determinemedical necessity.

Review the authorization request and medical information provided by the requesting provider for medical necessity and appropriateness, comparing information to current medical care criteria by health plan and as specified by BTP, CMS, CDC, NCQA and DMHC requirements.

Review all cases against the division offinancial responsibility(DOFR), Health Plan Ancillary Gridsand BTP Ancillary lists to ensure appropriate vendorsare utilizedfor payment of services.

Formulateappropriate denialletter language in accordance withIndustry Collaboration effort (ICE)and health plan requirements

Ensure accuracy of case data in Tapestry including ICD-10,CPTand HCPC codes

Participate in the annual inter-rater review to evaluate consistency of decision making with in the nursing staff Support Inpatient CareManagement, Network Management, Claims, Customer Service, Quality Improvement and Physician Services staff by offering benefit interpretation, understanding of UM policies and procedures and the application of guidelines in the process of decision making.

RN-Registered Nurse of California Licensurerequired.