- Prepare clinical reviews based on organizational guidelines and medical policies.
- Present recommendations to physician reviewers for final determination.
- Conduct prior authorization, concurrent, and retrospective reviews.
- Monitor clinical quality concerns and escalate outlier or complicated cases.
- Interact with external facilities and providers to gather clinical information for medical necessity reviews.
- Assist staff with coding, medical records, documentation, and claims appeals.
- Conduct telephonic outreach to members and perform motivational interviewing.
- Facilitate discharge planning and care coordination.
- Manage departmental escalations with urgency and accountability.