Marian R Email and Phone Number

Provides clinical review and decision-making following specific clinical coverage position criteria and established clinical guidelines for provider appeals. The nurse decision-making is based on the client's accepted clinical criteria sets, regulatory requirements, contractual benefits and specific customer medical circumstances. Coverage recommendations on claims and appeals that require further professional or committee review are referred to a medical director following established policies… Show more Provides clinical review and decision-making following specific clinical coverage position criteria and established clinical guidelines for provider appeals. The nurse decision-making is based on the client's accepted clinical criteria sets, regulatory requirements, contractual benefits and specific customer medical circumstances. Coverage recommendations on claims and appeals that require further professional or committee review are referred to a medical director following established policies and regulatory requirements. Conducts clinical determinations and/or recommendations on Post-service Inpatient, Outpatient, Pharmacy, Orthopedic, Genetic, and PxDx services for failure to prior authorize or denied as not medically necessary per the customer’s plan requirements using clinical criteria, the appropriate Nurse empowerment and/or physician referral policies. Show less

Primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing patients with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for patients to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and… Show more Primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing patients with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for patients to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Show less