Customer Service Rep- for Nurses ( clinical account) - QC
Full-time
Sagility Philippines B.V. Branch Office
• Accesses the appropriate coverage criteria.
• Performs Utilization Management review in accordance to federal and state mandated regulations, HUM URAC standards and client requirement and/or policies.
• Maintains compliance with regulatory changes affecting Utilization Management.
• Reviews the clinical information and treatment requests against established clinical review criteria, and determine if the criteria is met or not.
• Documents review.
• Protects and secures member’s Protected Health Information (PHI).
• Responds to inbound calls pertaining to reviews in a timely manner, following client-established protocols.
• Participates in discussion rounds with the Medical Director.
• Arrives at a medical necessity decision conducting one of the following 3 things as an end result:
o Nurse approves requests that meet the criteria
o Nurse contractually denies requests excluded in member contract
o Nurse routes requests not meeting criteria to RMD or refers for Peer-to-peer
• Notifies provider and member of decision through outbound calls
Vacancy posted 18 hours ago
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