*This position can be telework.
To assess and complete appropriate documentation for tracking and trending data. Responsible for written responses to all incoming correspondence, including all grievances from members, providers and outside agencies as well as second level and above appeals from members and/or providers for all lines of business.
Under direction, develops, implements, and coordinates medically necessary treatment services within PHC’s Health Services for adults and children with behavioral health and/or substance use disorder needs. Collaborates and coordinates care as part of the multidisciplinary team to evaluate and advocate for the medical, behavioral and psychosocial needs of the member while promoting quality and cost-effective outcomes.
The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term care and ancillary, DME or medical services.
To research and resolve provider telephone and written inquiries within established time frames, accurately screen claims, and participate in provider meetings and projects. To accurately research and process paper and electronic medical, outpatient, ancillary, long term care, CHDP, encounter data and paper crossover/other coverage claims within established time frames, applying appropriate program policies related to claims processing and analysis.
*This position requires a RN license.
The incumbent utilizes clinical judgement in providing utilization management services. The
focus is to provide high quality, cost-effective care which will enable patients to achieve
maximum medical improvement while receiving care deemed medically necessary. Assists in
determining appropriateness, quality and medical necessity of treatment plans using preestablished guidelines. This position may be assigned cases in long-term care and ancillary,
DME or medical services.
To initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member’s representative in a care plan that assists a member in meeting his/her health and wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet the comprehensive medical, behavioral, and psychosocial needs of the member, while promoting quality and cost-effective outcomes.
