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Identify cases eligible for medical reviews and assign these to appropriate reviewers.
Reach out to the client for any problems identified in the cases for review.
Adhere to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established MediCall best practice UM time frames, as appropriate.
Adhere to federal, state, URAC, client, and established MediCall best practice WCUM time frames, as appropriate.
Develop a complete understanding of the Medical management Procedures.
Perform medical review assessment (MRA) on utilization of health services (eg healthcare plans, workers compensation products etc) in an accurate, efficient and timely manner while ensuring compliance with utilization management regulations and adherence to state and federal mandates.
Provide succinct negotiable points based on the submitted medical records that identify necessary medical treatment, casually related care, response or lack of response to treatment, etc.
Identify missing records and information that are necessary in the completion of the medical review assessment.
Adhere to Department of Labor, state and company timeframe requirements.
Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
Track status of all utilization management reviews in progress and follow up on all pending cases.
Work closely with management team in the ongoing development and implementation of utilization management programs.
Respond to inbound telephone calls pertaining to medical reviews in a timely manner, following clientestablished protocols.
Process customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, eg opening and closing remarks.
Learn new methods and services as the job requires.
Ct:
HR KAMATCHI
Experience : 0 – 1 Years
No. of Openings : 50
Education : BDS, BAMS, B.Pharma, B.Sc, B.Tech/B.E, BVSC, M.Pharma, M.Sc, M.Tech, MVSC
Role : Nanotechnologist
Industry Type : Hospitals / Medical / Healthcare Equipments
Gender : [ Male / Female ]
Job Country : India
