Utilization Management Rn
Current-Assesses medical necessity by screening available information against established criteria, using Milliman Guidelines, Clinical Decision Support Tool, NCCN, NIH, FDA regulations, behavioral health criteria, and medical policy-Prepares and presents cases to Medical Directors- Provides oversight for prior authorizations and pre-determinations-Utilizes designated criteria along with clinical knowledge to make authorization decisions and assist with review determinations-Ensures accuracy in CPT-4 and ICD-10 codes-Collaborates with the appeals team in appeal process procedures-Serves as the new employee trainer for all on-boarding clinical staff-Advises non-clinical staff on clinical and coding questions-Meets standards for decision turn-around times and written correspondence-Contributes to the daily workflow with regular and punctual attendance.