- Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness.
- Evaluate clinical documentation to support level-of-care determinations and continued hospital stays.
- Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing.
- Collaborate with the Medical Director on complex cases, denials, and escalated reviews.
- Work with case managers and care teams to facilitate seamless care transitions and discharge planning.
- Ensure compliance with state/federal regulations, NCQA, and URAC standards.
- Educate providers and staff on clinical guidelines and authorization processes.
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