Responsibilities
- Complete timely review of healthcare services using appropriate medical criteria to support determinations.
- Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
- Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
- Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
- Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
- Identify and refer eligible members to disease management programs to enhance care quality and continuity.
- Manage and document on‑call phone communications with members and providers on a rotational basis.
- Maintain confidentiality of all member information and case records.
- Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
- Prepare benefit exhaustion letters upon request.
- Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
- Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
- Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.
Requirements
- Clinical expertise and regulatory knowledge in utilization review
- Ability to apply medical criteria for clinical determinations
- Clear and accurate documentation in compliance with federal/state regulations, URAC standards, and company policies
- Effective verbal and written communication with providers, organizations, members, and representatives
- Collaboration with Medical Director and Peer Reviewers for complex cases
- Experience in care coordination and member support
- Knowledge of disease management programs and referral processes
- Ability to manage on-call phone communications on a rotational basis
- Commitment to confidentiality of member information and case records
- Participation in quality management initiatives, reporting, and data collection
- Preparation of benefit exhaustion letters as needed
- Development and maintenance of clinical/client-specific reports, spreadsheets, and analyses
- Ongoing professional development in line with Illinois nursing regulations
