DE033374-Health Clinical Services Sr Analyst

ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE.

Position Title

Health Clinical Services Sr Analyst

Work Setup

Return to Office

Responsibilities

• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
• Re...