Keisa Cloudy

Serves as a resource to the Claims Department in determining the medical necessity of claims submitted by network and out of network physicians according to Health Solutions payor's prospective review criteria and authorization procedures

Coordinates precertification activities with contracted health plans and interfaces with providers and/or enrollees when precertification issues arise

Educates and affords training to network physicians/office staff on prospective review/precertification requirements

Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to support care management initiatives and sound decision making for review determinations

Utilizes InterQual, Milliman, and other Medical Management/health plan endorsed or developed criteria when evaluating cases for pre-authorization; considers special needs and other unique medical needs of enrollees as part of the evaluation process

Provides direction and answers phone inquiries from providers and enrollees regarding Health Solutions' pre-authorization program

Routes provider related UM complaints to correct department for documentation and investigation when calls are received directly from providers or enrollees

Conducts timely medical necessity reviews of all covered services in accordance with TDI, CMS, and other regulatory bodies and adheres to required timeliness

Establish/maintain good rapport with providers to obtain information necessary for review determinations

Present all cases that do no meet clinical criteria, questionable admissions, and prolonged length of stays to the Medical Director for determination

Collect accurate data for system input by using correct coding of diagnoses and/or procedures and utilizing complete and concise documentation of all pertinent information obtained

Assist the Director and Medical Director in identifying additional guidelines or protocols

Serves as a liaison with participating hospitals' Case Management staff in order to be apprised of inpatient admission status and care management needs; serves as a resource to the hospital staff by assisting in alternative care placements in compliance to applicable managed care plan

Identify enrollees in need of case/disease management and make appropriate referrals

Identify potential quality of care issues as it relates to data collected as part of the pre-authorization process, flags cases for review by the Appeals & Outcomes Coordinator

Comply with HIPPA regulations

Performs other related duties as requested by Supervisor, Manager, Director, and/or Medical Director

Maintain a 90% or greater score on the quarterly audit tool and IRR testing

Provide direct nursing care to an assigned group of patients, under the appropriate supervision of a Provider, Registered nurse, by applying clinical nursing knowledge, skills, and ensuring the safety and comfort of patients and families according to legal, organizational, and professional standards

Prioritize and makes judgement concerning basic needs of multiple patients in order to organize care

Assist with outreach initiatives and goals set forth by the Population Health leadership

Ongoing liaison between patient, multispecialty care departments and approved Facilities

Process incoming referrals to providers within a reasonable turnaround time according to Medicare guidelines, including but not limited to Home Health, DME, concurrent review, inpatient and outpatient surgical procedures, post acute, genetic testing, Medical Pharmacy, dental, vision, expedited and out of network requests

Serves as resource to the Claim Department in determining medical necessity of claim submitted by network physicians according to Health Solutions

Determine patient coverage, as well as carry out denial of service authorizations

Collect and process clinical information from Physicians and Providers, and make reasonable clinical decisions

Provide exceptional customer service

Construct denial letters for cases that do not meet specific guidelines and requirements

Interface with Providers and Customers and identify existing barriers

Refer customers to needed services, including but not limited to social services, transportation, food services, behavioral health, etc

Provide education to customers/families with chronic health conditions