Job Description
Responsibilities:
- Drive overall performance and manage Utilization Review team and process deliverables.
- Responsible for supervisory support through transaction monitoring and delivering results as per Service Level Agreement targets / timelines.
- Produce reports to gauge process performance. Steer process meetings / calls to a logical conclusion.
- In charge of managing 15 or more Utilization Review team
- Monitors daily operational tasks of his/her span and provides support when needed.
- Also able to do UR work when needed.
- (In charge of reviewing Medical necessity of medical procedures and treatments and may require decision making for UR claims.
- May require outbound calls to doctors or providers in case of missing documents that would be needed in the review.
- Initial Clinical Reviewer is allowed to make certifications and coordinate with Peer Reviewer for any Non-certifications.)