This position resides in the Medical Management Department. Included in this position are four aspects of medical necessity review : Pre-Authorization, Concurrent Review, Medical Claims Review and Appeals.
This position is responsible for :
Accurately issuing authorizations for appropriate procedures and diagnoses requiring preauthorization, using Milliman criteria, Medicare guidelines and medical policies within the established policies of the Clinical Management Department.
Identifying authorization requests that do not meet established guidelines, researching and obtaining all necessary clinical and historical information, and reviewing with the Medical Director for determination.
Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity / affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.