Associate Clinicians Nurses

As a Reviewer of Precertification Requests, your role involves evaluating requests for medical necessity based on clinical policy guidelines. Your responsibilities include: - Reviewing precertification requests to determine medical necessity according to established guidelines - Verifying the eligibility and benefits of members" coverage - Communicating effectively with network providers and members to gather additional information as needed - Providing unbiased recommendations based on the medical records provided - Collaborating with Medical Directors to refer cases that do not meet guidelines initially - Assessing the appropriate length of hospital stays using Milliman Care Guidelines - Ensuring efficient and timely reviews while meeting urgent and non-urgent turnaround time standards - Offering peer-to-peer reviews and appeals processes for case denials - Safeguarding the privacy of member information - Demonstrating effective multitasking and task prioritization skills - Completing all work within the specified turnaround time If there are any additional details about the company in the job description, please provide them for inclusion in the final JD.,