Nurse Case Manager - Utilization

Job description

Responsibilities: - Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach - Performs medical necessity review that includes concurrent, prospective, retrospective reviews and 1st level appeals, to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and vendor contracts. - Apply Milliman Care Guidelines, internal Policies and Reference Guides to determine appropriateness of services/equipment that require Prior Authorization - Maintain accurate records of all patient/provider/vendor related interactions in designated medical management system - Apply clinical guidelines, provide recommendations and discuss cases with Medical Consultants - Meet timelines and quality standards related to Utilization Management - Maintain and submit reports and logs on reviewed activities as outlined by the UM program operational procedures, - Identify and participate in quality improvement activities as it relates to internal programs, processes studies and projects - Authorize vendor services using clin...