Summary:

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right time.

Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.

Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.



Essential Functions:

Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.

Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.

Participates in interdepartmental integration and collaborati...