Lois Harrold RN, CMCN

Responsible for prior authorizations in the commercial line of business in a timely manner in accordance with NCQA and state of WV guidelines.

Assists Medicare and Medicaid Pre-Authorization nurse navigators as needed.

Assists in self-funded line of business as needed.

Refers cases to the Transition of Care team when indicated.

Refers cases to Nurse Navigator Case Managers as indicated.

Refers transplant cases onto the appropriate nurse.

Performs reviews for appeals and grievance department.

Utilizes Interqual, Local Coverage Determinations, National Coverage Determinations, Hayes, UpToDate and The Health Plan Medical Policies as needed.

Utilizes an ACD line for incoming calls.

Refers referrals onto the Medical Director as needed.

Compiles denial letters as indicated.

Notifies providers of denials and the rationale.

Telephonic and on site utilization chart review.

Prior authorization of Skilled and Rehab admissions.

Identified quality issues and referred onto the Quality Improvement Department.

Determined medical necessity utilizing Interqual Criteria and referred to Medical Director for review as needed.

Assigned length of stay.

Worked with local Cardiologist Monday-Friday.

Worked with Pediatric Cardiologist from West Virginia University on a monthly basis.

Triaged patients.

Escorted patients to exam room, Performed EKG's and vital signs.

Telephone prescriptions to pharmacy.

Monitored laboratory work and orders.

Took patient phone calls.

Staffed with physician daily with lab work work results and patient concerns.

Charge nurse supervising nursing staff.

Passed medications to residents.

Responsible for admissions while on duty.

Assured the safety of residents and staff.

Care planning.

Making rounds with physicians.