Documents all activities in the appropriate system(s) on a timely basis

Reviews individual medical cases to confirm that they are getting the most appropriate care.

Weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment.

Promote the quality and cost effectiveness of medical care by applying clinical knowledge and the appropriate application of policies and guidelines to prior authorization requests.

Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence-based standards.

Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, and outpatient services and out of network providers

Determines the appropriate level of care for patient stays in acute care facilities in compliance with acute care guidelines; prior authorization medical necessity review, including determination of appropriate provision of observation care, outpatient or inpatient rehabilitation services, DME, Home Health and other ancillary healthcare services in compliance with approved care guidelines

Accurate, thorough and efficient review of authorization requests

Timely review of prior authorization requests, both inpatient and outpatient

Acute hospital pre-admission / Skilled Nursing Facility / Hospice and other Long Term Care facilities

Surgical / Diagnostic procedures / Therapies / Durable Medical Equipment and Home Care;

Determines utilization decisions based upon nationally recognized and evidence based guidelines

Reviews prior authorization requests with Medical Directors as directed