Performs pre-service authorization reviews to obtain payment authorization for both inpatient and outpatient services. Succinctly abstracts fact based clinical information to support pre-authorization utilizing applicable nationally recognized and payer-specific criteria.
Communicates timely the clinical information supporting the medical necessity of an ordered test / treatment / procedure / surgery as applicable to the patient’s health plan and documents the outcome of the task.
Performs the following activities to support the effective operation of the organization’s quality management system.
Participation in quality control audit process; participation in department projects and activities to improve overall company and client scorecard metrics.
provides feedback regarding improvement opportunities for workflow & / or procedures; and the contributes to successful implementation of all the above.
Demonstrates proficiency in the use of multiple electronic tools required by both the company and its clients.
Collaborate with and engage internal and external customers, such as facility patient access and physician offices, in opportunities for prevention of future disputes;
identifies potential process gaps and recommends sound solutions to CAS leadership.
Must possess an active nursing license (Registered or Practical / Vocational). Licensed Nurse Practitioner / Registered Nurse.
Experience in Utilization Review, Utilization Management, Case Management, Pre-Authorization in a payer or acute care setting;
preferably medical-surgical or critical care / ED.