Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations. Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance. Analyzes clinical service requests against evidence-based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay. Conducts reviews to determine prior authorization/financial responsibility. Processes requests within required timelines. Refers appropriate cases to medical directors. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams. Adheres to utilization management policies and procedures.
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