Description
Job Summary:
Responsible for carrying out precertification and medical necessity reviews on all designated referrals as well as targeted outpatient procedures, services and inpatient admissions. The activities will include telephonic review for medical necessity of the RN designated targeted outpatient procedures, services and inpatient admissions, as well as referrals, utilizing established criteria and guidelines, retrospective ED reviews. In addition, they will perform eligibility and benefit reviews as necessary, identification of patients for case management, quality improvement reviews, and communicate with inpatient care coordinators, case managers, the SNF/Rehab care coordinator, members, providers, customer service, claims, contracts and benefits, appeals and risk management.
Essential Responsibilities:
- Responsible for the day to day precertification and review activities as outlined above.
- Utilizes established criteria to perform precertification and referral review for all members requiring a procedure or service or with an admission diagnosis on the targeted review list for the RN.
- All referrals and precertification reviews will be performed within the required timeframe and the provider and member notified of the results.
- Refers all cases that do not meet established criteria to the appropriate review physician.
- Performs questionable benefit and eligibility reviews.
- Provides investigation and preparation of cases requiring review of the Physician Program Director of QRM: Non Contracted Providers Question of internal referral versus external referral or non-contract consultant performing services that can be provided internally. Any referral questionable for benefit Breast Reduction/Augmentation Varicose Veins Possible experimental/investigational procedures or treatments TMJ diagnoses. Referrals that are not approved due to not meeting medical appropriateness criteria.
- Understands the Complex Case Management Program and admission criteria and refers patients to the Complex Case Managers as appropriate.
- Provide correspondence, written and verbal, in accordance to policy and procedure for members with respect to referrals.
- Provides review of pended bills for specific types of referral cases.
- Interacts with physicians to ensure that resources are being utilized appropriately while maintaining quality outcomes.
- Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed.
- Refers the patient to the home care review team and/or social workers as appropriate.
- Ensures that care is being delivered in the most appropriate setting based on established criteria and guidelines.
- Performs quality of care and service reviews using identified quality indicators.
- Coordinates and assists the Specialty Care Review Services Supervisor with ongoing physician education.
- Reviews the monthly analysis of statistics (cost/benefit) with the Specialty Care Review Services Supervisor and makes adjustments based on findings.
- Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
- Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, the SNF rounder, home care review team, social workers, inpatient care coordinators, referral coordinators, Member Services, Claims, Contracts and Benefits-Appeals, Risk Management and Kaiser Permanents medical offices to facilitate the precertification and referral process.
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