BASIC FUNCTIONPerform and administer level 2 Medical Review Pre-Determinations according to benefit language and standard medical care.ENVIRONMENTThe Health Managed Department is responsible for developing, implementing and administering private business and government utilization review, medical review, cost containment, reconsiderations, and post payment audit programs to assure optimization of cost savings to the company regarding medical claims. The Medical Review Unit develops, implements, and administers programs such as Medical Review and Preferred Medical Doctor, to determine medical necessity of services and impact cost savings.WORKFLOWWork is received via fax or mail from providers, groups and subscribers. Incumbent performs reviews of proposed procedures to approve reimbursement or denial of services. Incumbent performs special projects to investigate propriety of PMD and claims and assures PMD guidelines are followed. Incumbent provides weekly reports on request activities. Incumbent prepares reconsideration case for Level III review. The incumbent creates allow or reject on each contract for which a decision has been rendered. The incumbent researches and suggests changes to guides according to the most recent scientific literature.KNOWLEDGEIncumbent must have a thorough understanding of medical practice that can be obtained through a nursing degree program or experience required to obtain Registration (RN) from the state. The incumbent must know claims payment guidelines, billing guidelines, laws and contracts that govern the health insurance program administered by this corporation. The incumbent must be able to discuss coverage guidelines and benefit issues with physicians, group administrators, or internal customers. The incumbent must be able to assist groups in benefit design within the parameters of cost and standard medical care.THINKING REQUIREMENTS:The incumbent must be an independent thinker and therefore able to work closely via personal, written or oral communication with representatives and officials of public, private and governmental agencies and professionals inside and outside the Corporation. These groups include the provider financial and medical representatives, customer representatives, and Blue Cross and Blue Shield representatives.INTERFACES AND INTERPERSONAL SKILLS:Incumbent has contact with groups, providers and their office representatives, subscribers and internal departments involved with Marketing and claims processing. This contact is usually one to one. However, it can be in the form of a presentation to large audiences. Frequently, the provider or subscriber is frustrated and angry and incumbent must be able to establish effective communications to resolve problems.AUTHORITY AND DECISION MAKING:Incumbent decides medical necessity of particular procedure in accordance to contract limits and standard medical practice, and resolves problems for subscribers, groups and providers. Incumbent represents Blue Cross and Blue Shield of Alabama when performing before a large group.PRINCIPAL ACCOUNTABLITIES
- Activity: Perform medical and utilization predeterminations of PMD and/or non-PMD providers both in state and out. End Result: To determine if coding is correct and procedures filed were medically necessary in order to control and reduce medical care costs
- Activity: Respond to telephone or written requests for information from Subscribers and providers. End Result: To provide requested information to solve claims problems
- Activity: Perform special projects with requested guidelines End Result: To investigate costs associated with PMD to assure compliance with PMD guidelines
- Activity: Prepare dialogue and support materials for workshops thorugh the state, as directed, for groups, agencies or providers. End Result: To educate groups, providers, and subscribers in total program concepts
- Activity: Assist in the development of new preferred care programs and their guidelines. End Result: To expand health management products, control costs and reduce overall medical expenses