Primary Responsibilities

This position reviews the clinical appropriateness of prior authorization (PA)/concurrent requests and ensures that all benefits authorized meet medical necessity and other Medicare guidelines to promote cost-effective delivery of health care services.

Essential Functions

Review PA requests for home health services, durable medical equipment, outpatient therapies, skilled nursing facility therapies, and all outpatient procedures pursuant to applicable Medicare and Medicaid criteria, Interqual guidelines, and PA Department policies and procedures. Review PA requests for inpatient medical stays, skilled nursing facility stays, long term acute hospital stays, inpatient rehabilitation facility stays Participates with facility discharge planners, Care Coordinators/Care Managers in coordinating the member’s discharge needs. Monitors inpatient and subacute activity daily for outcomes related to readmission, utilization, quality of care and provider performance in compliance with TIHP policies. Provide complete and accurate documentation specifying rational for approval, r for forwarding to the CMO/Medical Director for further review. Create reduction/denial letters based on the Medical Director’s review and applicable guidelines. Maintain a thorough understanding of Medicare guidelines and stay abreast of updates and changes.

Work in collaboration with the PA staff to ensure timely and efficient completion of all workflows within the Department.