Purpose of Positon: To assure the medical necessity and appropriateness of health care service including admissons, outpatient services, referral for disease and case management and use of ancillary services.

Responsibilities:  Perform phone triage for utilization management activities including, but limited to:

• Prospective review of in-patient admissions and ambulatory medical services to ensure services are medically necessary, eligible and provided by a contracted provider.
  
• Concurrent review contact for assessment of ongoing medical services such as DME rental or Home Care for appropriateness.
  
• Restrospective review for determinations of eligibility, medical necessity, and appropriate ER utilization.
  
• Assist Member Services and/or Claims Research team with investigation of problems related to coverage levels and benefits.

Perform data entry for initial authorizations including but not limited to:

• In and Out Patient stays, home health care infusion therapy and DME/orthotic/prosthetic services.
  
• Serve as a liaison for the Networks, Case Managers, Disease Management staff for utilization issues.
  
• Initiate calls to INN providers to confirm what services are available when OON providers are being utilized for services
  
• Generate approval and denial letters.