Joci Edwards

Review and evaluate proposed services according to GHC-SCW program guidelines.

Assess medical records for pre-certification and predetermination approvals or denials.

Document criteria used for determination of medical necessity.

Determine appropriate levels of care based on MCG criteria.

Ensure compliance with medical decision policies with medical policies and group contract provisions.

Refer complex utilization management cases to care management manager or medical director.

Verify inpatient admissions and approve initial lengths of stay.

Participate in monthly UM review meeting with the Care Management Department Manager.

When unable to approve services, gather and prepare relevant data in an organized format for the Medical Director to review and make informed decisions.

Assist with second review of claims as needed.

Maintain knowledge of current NCQA guidelines.

Monitored quality of care and reported findings to management potential quality of care issues to appropriate personnel.

Abstracted information from medical records for authorization requests regarding acute and primary health care services.

Conducted clinical reviews based on medical necessity criteria, adhering to InterQual, MCG, and DHS guidelines.

• Documented rationale for coverage decisions to ensure clarity and compliance.
• Collaborated with providers and care management staff to facilitate appropriate member care.
• Engaged in complex member issues with care management to develop tailored solutions.
• Reviewed requests alongside medical director as part of secondary review process.
• Utilized clinical assessment and judgment when evaluating authorization requests for healthcare services.

Collaborated with care team to deliver community-based management services and improve patient outcomes.

Conducted comprehensive assessments and implemented evidence-based nursing interventions.

Coordinated access to cost-effective long-term care services and resources.

Performed utilization reviews and arranged durable medical equipment and home health therapy.

Developed risk reduction strategies targeting health, safety, and functional improvements.

Provided education on prevention and wellness to enhance member awareness.

• Facilitated coordination of acute and primary care services for seamless transitions.
• Partnered with service providers to align resources with member need