Ashley Borders

* Review and collect medical information for medical necessity of services.

* Communicate with healthcare providers involved in the care of the member.

*Demonstrate time management and priority setting skills.

* Determine appropriate utilization management of services requested.

* Ensures that services provided are within benefit plan and appropriate contracted providers are being utilized.

* Identity and refer appropriate cases to case management.

* Identify appropriate clinical settings for services being requested.

• Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
• Performed prior authorization review of services requiring notification.
• Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.