RN, Specialty Care Review

Responsible for carrying out medical necessity reviews on all designated referrals for Home Care, DME Specialty Care services. Activities include telephonic review for medical necessity using established criteria, eligibility and benefit reviews, identification of patients for case management, quality improvement reviews, and communication with various departments. Utilizes established criteria to perform medical necessity review for all members requiring home health and DME services. Refers cases not meeting criteria to review physician. Performs benefit and eligibility reviews, investigates cases for Chief of QRM, refers patients to Complex Case Managers, and interacts with vendors. Maintains contact with case managers, refers patients to social workers, performs quality of care reviews, and reviews utilization reports with Supervisor. Remains knowledgeable of contract benefits, state and Federal regulations, and laws affecting managed care and case/utilization management. Participates in call rotation for after-hours and weekend requests. Issues letters of non-coverage to members not meeting criteria. Works cross-functionally with other departments.