Utilizes clinical experience and skills in a collaborative process to assess,plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
Communicates with providers and other parties to facilitate care/treatment.
Identifies members for referral opportunities to integrate with other products, services and/or programs.
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.