• Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources
• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources
• Work with medical directors in interpreting appropriateness of care

Responsibilities:

• Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources
• Ensures medically appropriat...