The Pre-Certification Reviewer is responsible for the pre-certification of Plan determined procedures utilizing approved criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Evaluate requested services following Plan approved criteria.
Demonstrate effective communication methods and skills, using lines of authority appropriately.
Establish a relationship with providers in order to determine/provide needed services for members
Arrange discharge planning services prior to pre-planned admissions when available.
Act as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintain accurate record of pre-certification decisions
Perform decisions within time frames required by regulatory agencies.
Adhere to quality standards and confidentiality policies and procedures.
Ensure compliance with all state and federal regulations and guidelines in day-to-day activities.
Perform other duties as assigned
Adapt to changes in policies, procedures, new techniques and additional responsibilities.
QUALIFICATIONS AND REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: Florida licensed RN or LPN required; minimum of two to three years varied clinical experience required; managed care experience preferred; or an equivalent combination of education, training and experience.
NECESSARY KNOWLEDGE, SKILLS AND ABILITIES: Ability to read and interpret documents, ability to calculate figures and amounts, excellent communication skills, good grammar, voice and diction, proficient in MS Office, basic computer and keyboarding skills, excellent customer service skills (friendly, courteous and helpful).
LICENSING AND CERTIFICATION: Florida licensed RN or LPN required.
PHYSICAL DEMANDS: The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit. The employee frequently is required to use hands 10 finger, handle, or feel objects, tools, or controls and talk or hear.
Specific vision abilities required to this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
WORK ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
For the most part ambient room temperatures, lighting and traditional office equipment as found in a typical office environment.
ADDITIONAL INFORMATION: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.
Freedom Health - 2 years ago
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