The Medical Management Specialist reviews documentation for appropriateness of service/medical necessity of services. Evaluation is made by the utilization of accepted medical criteria and Medical Management Policy. The purpose of this position is for the processing and coordination of all levels of member/provider authorizations.
- Obtains and evaluates required clinical information to process requests
- Receives, reviews, and processes requests for medical appropriateness per the Prior authorization list
- Performs precertification activities related to both inpatient/outpatient services in accordance with predetermined departmental criteria and use of national clinical guidelines
- Acts as a liaison between business partners and contracted vendors
- Promotes member and provider satisfaction by assisting providers in verifying member benefit/ eligibility information
- Maintains accurate and timely documentation of inquiries and ensures appropriate follow up per department guidelines
- Ensures that members are using in network providers. Coordinates with Provider Relations for all out of network requests
Please be advised that we are only considering nurses with the following:
How Pathway Medical Works with You to Get the Job:
- Associates Degree in business, health care or related field
- 1-2 years experience in a managed care/ medical management healthcare setting
- Claims/ Coding experience a plus
Since 1998 we have focused exclusively on helping nurse case managers and related non-bedside nursing professionals find career opportunities that fit their lifestyle and advance their careers.
- We have long-standing relationships with nurse executives at dozens of leading healthcare organizations, ensuring that your accomplishments and skills get noticed by key decision makers .
- We will review your resume to make certain it emphasizes the important skills and experience requirements of the job for which you are applying.
- We will then prepare you for your interview , enabling you to show why you are the best candidate for the job.
- When an offer is extended we will help you negotiate compensation , benefits and any additional employment issues.
Medical Staffing Network Care Management
- 2 years ago - save job