Abigail Haag

Evaluated medical necessity of services through comprehensive utilization reviews. Determined appropriate care levels by analyzing patient records and treatment plans. Conducted compliance reviews of inpatient utilization against admission criteria. Maintained conformity with federal, state, and accreditation regulations in utilization management.

Performed retro, reconsideration, and appeal reviews of inpatient utilization for adherence to admission criteria.
Analyzed clinical documentation for precision and thoroughness to support coverage decisions.
Determined service medical necessity utilizing established review protocols.

Review medical records and verify if the requested service meets criteria.

Review post service claims for clinical eligibility for coverage as prescribed by the Plan benefits.

Review and interpret Plan language.

Coordinate reviews with the Medical Director.

Utilize clinical guidelines and criteria.

Responsible for accurately documenting determinations.

Adherence to all confidentiality regulations and agreements.

Making outbound calls to assess members' current health status. Utilizing Milliman criteria to determine if patients are in the correct hospital setting. Coordination of member's care through the health care continuum. Collaborate with member, provider, facility to obtain best outcome. Review cases with Medical Directors daily on challenging cases as needed. Documenting and tracking findings