As a Reviewer of Precertification Requests for Medical Necessity, your role involves evaluating requests based on clinical policy guidelines. This includes: - Providing unbiased recommendations on medical necessity by analyzing medical records from requesting parties. - Collaborating with Medical Directors to refer cases that do not meet the established guidelines initially. - Reviewing the appropriate length of hospital stays using Milliman Care Guidelines. - Conducting efficient and timely reviews while adhering to urgent and non-urgent turnaround time standards. - Offering peer-to-peer reviews and participating in the appeals process for case denials. In addition to these responsibilities, you will be required to: - Verify the eligibility and benefits of members" coverage. - Gather additional information from network providers and members as needed. - Maintain the privacy of all member-related information. The company values effective multitasking, task prioritization, and working comprehensively within specified turnaround times.,

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Associate Clinicians Nurses