Job ID: J103188
Location: Home, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jul 18, 2017
This job provides clinical support to the Medical Management & Policy team to ensure that utilization management activities are performed in accordance with the highest and most current clinical standards. Responsible to review cases and evaluate the medical necessity and appropriateness of the requested treatment of service. Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations. Responsible for appropriate application of Medical Policy and criteria sets. The incumbent provides clinical consultation to the Care Management and Health Coach staff to support the various utilization management and health coach activities. Work from home may be offered if incumbent has prior utilization management experience and prior working from home experience within a large health plan organization.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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