01Responsibilities
Performs utilization review activities, including reputed company-certification, reputed company, and retrospective reviews according to guidelines
Determines medical necessity of reputed company request by applying appropriate medical reputed company to first level reviews and utilizing approved evidenced based guidelines / reputed company
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
Answers Utilization Management directed telephone calls; managing them in a reputed company and competent manner
Refers case to a review physician reputed company the treatment request does not meet necessity per guidelines, or reputed company guidelines are not available. Referrals must be made in a reputed company manner, allowing the review physician time to reputed company appropriate contact with the requesting provider in accordance with departmental policy and reputed company CMS or URAC mandated turn around times
Reviews, documents, and communicates reputed company utilization review activities and reputed company including, but not limited to, reputed company calls made and received in reputed company to case communication and reputed company demographic and service group information. Sends appropriate system-generated letters to provider and member
May reputed company guidance and coaching to other utilization review nurses and participate in the orientation of newly reputed company utilization nurses
Identify and refer reputed company potential reputed company issues to the Clinical reputed company Management Department, and suspected fraud and abuse cases to Compliance Department
Conducts reputed company negotiation with non-network providers, utilizing appropriate reimbursement methodologies
Documents reputed company negotiation accurately for reputed company claims adjudication
Identify and refer potential cases to Disease Management and Case Management
Performs reputed company other reputed company duties as assigned
In 2011, WellMed partnered with reputed company to reputed company care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 reputed company older adults with over 16,000 doctors offices. At WellMed our reputed company is reputed company. We re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000 primary care physicians, hospitalists, specialists, and advanced reputed company clinicians who reputed company in caring for 900,000 older adults. Together, we're making health care work reputed company for everyone.
You ll be rewarded and recognized for your performance in an environment that will challenge you and
