About the job
Join our dedicated team in the Continued Stay Review Department, where you will evaluate incoming urgent inpatient admissions for medical necessity. We seek candidates with strong computer skills, a positive attitude, and the ability to achieve high production goals. You will be expected to review approximately 20 cases daily, maintaining a remarkable accuracy rate of 95%.
Your role will involve collaborating with healthcare providers and members to ensure quality member outcomes, optimize benefits, and promote efficient resource utilization.
Key Responsibilities:
- Assess the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and treatment settings, utilizing medical policy and industry standards.
- Apply clinical expertise to coordinate care with facilities and providers.
- Collaborate with medical directors for accurate claims payment and care appropriateness.
- Manage appeals for denied services when necessary.
- Conduct various reviews (precertification, inpatient, retrospective) to ensure compliance with medical policy and member eligibility.
- Ensure members have access to necessary, high-quality healthcare in cost-effective settings.
- Work with clinical reviewers and medical directors throughout the medical management process.
- Assist in discharge planning by identifying member needs early in the process.
- Facilitate member care transitions and ensure proper treatment planning.
- Maintain accreditation standards through knowledge of regulatory requirements.