Medical Reviewer
Current* Delivering high quality compliant medical necessity reviews for all ages, preauthorization, concurrent, and retrospective, for Commercial, POS, and Medicare, including Behavioral Health, and Pharmacy benefits.* Review efficient and timely, Appeals, Grievances, Utilization Management, and Claims reviews.* Ensure Commercial and Medicare plan members receive appropriate and evidence-based reviews per Plan Benefits, Health Plan Clinical Policies, MCG Health Ambulatory Care guidelines, CMS, NationalComprehensive Cancer Network (NCCN), Hayes Technology Assessment, UpToDate, and current WPATH standards of care.* Updated Health Plan clinical benefit policies. Developed new clinical policies such as: Genetic Testing For An Inheritable Disease HS-CP-G2, Biomarker Testing To Guide Targeted Cancer Therapy HS-CP-G3, Pharmacogenetic Testing For Drug Metabolism HS-CP-P6, Proton Beam Radiation Therapy HS-CP-P7, Preventative Services HS-CP-P5.* Participated in Peer Review Committee, Pharmacy & Therapeutic Committee, Quality Management Committee, Joint Operating Committee, and Clinical Policy & Technology Assessment Committee.
