Job Summary:


Responsible for carrying out medical necessity reviews on all designated referrals for Home Care, DME Specialty Care services. The activities will include telephonic review for medical necessity of the designated services using established criteria and guidelines for coordination of services. Eligibility and benefit reviews will be performed as necessary. Identification of patients for case management, quality improvement reviews, and communication with inpatient care coordinators, case managers, providers, Customer Service, Claims, Contracts and Benefits - Appeals, Risk Management are responsibilities of the position.

Essential Responsibilities:


+ Responsible for the day to day review activities as outlined above. Utilizes established criteria to perform medical necessity review for all members requiring home health and DME services. All referral reviews will be performed within the required timeframe and with adherence to the decisio...