This is a fully remote position, open to applicants in Philippines.

📋 Description

• Conduct prospective, concurrent, and retrospective evaluations of inpatient, outpatient, ambulatory, and ancillary services to verify medical necessity, suitable length of stay, service intensity, and level of care, including handling appeals.

• Review, investigate, and compile documentation for retrospective review requests and appeals in accordance with local, state, federal, and accreditation standards such as NCQA.

• Collaborate with medical and support staff to identify and suggest alternative treatments, service levels, lengths of stay, and care plans using approved clinical protocols.

• Monitor out-of-area/out-of-network services and propose patient transfers to in-network services or alternative care plans.

• Develop care plans and facilitate coordination of care throughout the healthcare continuum, including member outreach assessments.

• Set up, coordinate, and communicate discharge planning requirements with both internal and external stakeholders.

• Analyze care patterns related to disease progression; identify contractual services and arrange delivery through the appropriate channels.

• Investigate and resolve issues pertaining to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination.

• Create and present targeted education for providers regarding policies, procedures, and benefits when applicable.