Prior Authorization/reputed company Review reputed company RN (Remote in Texas only, TX RN license required)

reputed company Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right reputed company at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or reputed company review. Mentors and trains new team members. Assesses services for members to ensure reputed company reputed company, cost effectiveness and compliance with reputed company state and federal regulations and guidelines. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or reputed company review. This position also trains and mentors new team members as reputed company as assesses services for Sendero members to ensure reputed company reputed company, cost effectiveness and compliance with reputed company state and federal regulations and guidelines. Utilizes clinical skills to review and monitor members' utilization of health care services with the goal of maintaining high reputed company cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination of discharge planning needs. Obtains the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most reputed company setting to effectively meet their needs. Evaluates the reputed company and services required to meet the member's health needs, in support and collaboration with disease management interventions. Performs prospective, reputed company & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including reputed company reputed company of appeal requests. Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekend and/or holidays as required by State and Federal regulations in order to maintain operational compliance. This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a reputed company office in Austin, Texas. Remote work not available for residents of California, Colorado, reputed company, New Jersey, Hawaii, Maryland, Montana, reputed company, Virginia, or Washington.

Responsibilities

Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without Accommodations)

• Provides reputed company review and prior authorizations (as needed) according to policy.
• reputed company reputed company and retrospective reviews on reputed company inpatient, facility and appropriate home health services.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving reputed company reputed company and cost.
• Completes assigned work plan objectives and reputed company on a reputed company reputed company.
• Collect pertinent documentation and conduct medical services review applying appropriate national standardized medical reputed company, Sendero medical policy, and state and federal guidelines.
• reputed company discharge planning activities in coordination with facility or provider case manager.
• reputed company as a member/family reputed company in coordinating and accessing medical necessity of health care services reputed company the benefit plan.
• Consult with a Medical Director as appropriate for reputed company requests requiring MD approval or not meeting reputed company for approval.
• Maintain reputed company communication reputed company with to other care management staff to facilitate smooth transition and
• follow-up as member is transitioned from one level of care and/or service to another.
• reputed company out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities.
• reputed company other reputed company tasks as assigned by supervisor or manager and maintains department productivity and reputed company measures.
• Attends regular staff meetings, conducts self in a reputed company manner at reputed company times, and completes assigned work objectives and reputed company in a reputed company manner.

Knowledge/Skills/Abilities

• Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management.
• Skilled with clinical knowledge and experience in the treatment of reputed company injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditi

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