Sr. Specialist - Case management - UR

Job Summary

Responsible for managing concurrent review processes and case management activities in accordance with medical necessity guidelines and utilization management policies. The role focuses on reviewing ongoing hospitalization cases, ensuring appropriate treatment, and driving cost-effective care throughout the patient journey.

Key Responsibilities

1. Case Review & Management

• Conduct concurrent reviews for pre-authorized admission cases, including long-stay (over 3 days) and complex cases.
• Assess medical reports and treatment plans to ensure clinical appropriateness and adherence to guidelines.
• Monitor high-cost cases and escalate to the medical team when necessary.
• Coordinate with medical consultants for cases that fall outside standard criteria.

2. Cost Management & Optimization

• Verify ...