Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met
Evaluate itemized bills against reimbursement policies
Adheres to quality assurance standards
Serves as a resource to facilitate understanding of products
Handles some escalated cases; secures supervisory assistance with problem solving and decision making
Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals
Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally
Analyze clinical information
Perform claim reviews with focus on coding and billing errors
Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
