Medical Review Representative

Job Specifications:

1.     Graduate of Bachelor's Degree – RN License is required.

2.     Minimum of 1 year experience and must have impressive track record in collecting, processing and monitoring routine to moderate complex referrals and health care services data and reviewing treatment plans and services in order to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources. 

3.     Effective team player. With very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.

4.     Must have behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.

5.     Outstanding oral and written communication skills.

6.     Strong ethics and a high level of personal and professional integrity.

7.     Must have basic familiarity with government rules and regulations relating to healthcare management.

8.     Computer literate and very highly proficient in using MS office programs.

Duties and Responsibilities:

1.     Medical Referral

1.1.  Inputs and processes authorization requests and authorizations per guidelines and according to defined time and accuracy standards.

1.2.  Reviews the health plan and other guidelines to ensure that services being provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized. 

1.3.  Issues letters of authorization and applies appropriate contracted or negotiated rates using established criteria.

1.4.  Provides members with verification of eligibility, interpretation of benefits, and appropriate contracted provider/facility.

1.5.  Screens and troubleshoots calls or walk-in's regarding member care within scope of position. Routes members and provider concerns outside that scope to appropriate department or co-employees.

1.6.  Maintains effective communication with members, providers, and other TakeCare staff to ensure adherence to company policies, guidelines, and processes.

1.7.  Corresponds with TakeCare Guam for coordination of members' off-island referrals.

1.8.  Administers reports and maintains files of correspondence, medical records, and other documentation, as appropriate, to report status and to support workflow.

2.     Medical Review/Medical Management

2.1.  Reviews and analyzes medical information and provides assistance in reviewing, evaluating and determining the medical necessity of service treatment requests to ensure that treatments are consistent with patient's diagnosis. 

2.2.  Ensures correct and consistent application of decision support system i.e., Medical Management Guidelines, Milliman Care Guidelines, etc.

2.3.  Determines appropriateness of services based on consistent application of decision support system and takes responsibility in communicating this to providers, members, and co-employees in a timely and effective manner.

2.4.  Supports the Medical Review Specialist, Medical Review Team Lead, Medical Referral Supervisor, and other members of the Medical Review/Medical Management Team in the review and analysis of medical information to determine the medical necessity of requested services according to review standards. 

2.5.  Works with the Medical Review/Medical Management Team to determine medical necessity and length of stay based on the consistent application of decision support system and communicates decisions to providers and patients.

2.6.  Works with the Medical Review/Medical Management Team in the coordination of discharge planning with physicians, members, families, caregivers and ancillary providers to support the member's continuity of care needs.

2.7.  Provides reports on the quality-of-care issues. Submits reports and communicates in a timely and effective manner to the Manager of the Medical Referral Office.

2.8.  Maintains ongoing database/documentation to monitor all activities/treatment and outcome plans for patients' conformance with organizational and government regulations.

2.9.  Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.

2.10.  Coordinates out of area cases ensuring patient receives cost-effective quality care and monitor patient for return to work.

Performs other duties that may be assigned from time to time.