DE033374-Health Clinical Services Sr Analyst

ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE---

WORK SETUP: Return to Office

• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
• Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes medical necessity denial determinations.
• Promote member access to medically necessary, quality healthcare in a cost-effective setting according to contract. Consult with clinical reviewers and/or U.S.-licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborate with providers to assess members, needs for early identification and proactive planning for discharge planning. Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required.
• Determine contract and benefit eligibility; obtain/confirm intake (demographic) information from callers and/or faxes.
• Conduct a thorough radius search in "Provider Finder" and follow up with provider on referrals given; refers cases requiring clinical review to a nurse reviewer.
• Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. Verify benefits and/or eligibility information. Check benefits for facility-based treatment.
• Review of information and summarization of member's potential care needs and/or durable medical equipment (DME) needs following discharge and forward to client for final discharge plan.
• Data entry of contact into client systems and route as appropriate.

Project/Team Location: Taguig, Uptown Bonifacio Tower 3