External Description:
Pre-Authorization Coordinator

GENERAL SUMMARY
Responsible for implementing and coordinating all utilization management
functions relating to pre-authorization of outpatient testing/surgery, and
inpatient admissions.

ESSENTIAL RESPONSIBILITIES
- Assists with the orientation of providers to the Plan's authorization and
review procedures and work closely with participating physicians to secure
information necessary for utilization management.
- Implements and documents utilization management activities which incorporate a
thorough understanding of clinical knowledge and appropriateness of medical
services related to effective cost containment.
- Assures the medical necessity and appropriateness of the delivery of
healthcare resources provided to members as per their benefit package, through
medical review of inpatient and outpatient service requests, utilizing
established criteria, clinical judgment, and Medical Director guidelines.
- Actively participates in the negotiation and notification processes that
result from the medical record reviews with the facilities. Prepares
notification letters of denied and negotiated days within the established...

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