Medical Services Nurse Staff

2 weeks ago


Meadville, United States Meadville Medical Center Full time
strong>$5,000 SIGN ON BONUS

Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials.

Clinical documentation specialists is designed to improve the physician's documentation in the patient's medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient.

Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff.

Employee insurance liaison

Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. br>
Medical necessity rules will be reviewed, urgency and medical history. They will review with the medical director and make a decision to override the out of network rules.

Committed to life-long learning

UM Process
  • Payors may use different criteria and may require their data set be applied for their population.
  • Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement
  • Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.


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