Responsibilities
- Evaluate healthcare services promptly using established medical guidelines to determine coverage or necessity.
- Record clinical assessments and decision rationale accurately and clearly per federal and state regulations, accreditation standards, and organizational policies.
- Deliver precertification and ongoing review outcomes to relevant stakeholders through verbal and written communication within required timeframes.
- Collaborate with Medical Directors and Peer Reviewers when cases involve complex medical necessity, treatment appropriateness, or quality assessments.
- Engage regularly with ordering clinicians, healthcare organizations, and, when applicable, patients or their authorized representatives.
- Recognize and direct qualifying individuals to disease management programs to improve care coordination and health outcomes.
- Respond to after-hours calls from providers and members on a rotating on-call schedule, ensuring proper documentation.
- Safeguard the privacy of all patient information and case documentation in compliance with confidentiality standards.
- Support quality improvement efforts through participation in data reporting, documentation, collection, and related committee functions.
- Generate benefit exhaustion notifications upon request.
- Contribute to the development and upkeep of clinical reports, client-specific analyses, spreadsheets, and data summaries.
- Stay current with evolving regulatory requirements, multi-state compliance standards, medical group protocols, and URAC guidelines.
- Pursue continuous professional development in alignment with Illinois nursing licensure standards and modern clinical practices.
