Manager

• Adhere and perform timely prospective review for services requiring prior authorization as well as timely concurrent review for continuation of care services
• Follows the authorization process using established criteria as set forth by the payer or clinical guidelines
• Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services
• Refers to the treatment plan for clinical reviews in accordance with established criteria and guidelines
• Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team
• Identifies potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serves as a resource to provide education regarding payer policies and assists with coordination of alternative treatment options
• Ensures and Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient.
• Proactive communication with leadership regarding barriers and or potential delays in care
• Identifies opportunities for expedited requests and prioritizes caseload accordingly
• Maintains knowledge regarding payer reimbursement policies and clinical guidelines

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Shift Manager I