• Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.
• Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
• Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes denial determinations.
• Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consult with clinical reviewers and/or U.S. licensed medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge planning.
• Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required.
Equal Employment Opportunity Statement
All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.
Job candidates will not be obligated to disclose sealed or expunged records of conviction or arrest as part of the hiring process.
Accenture is committed to providing veteran employment opportunities to our service men and women.
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