Responsibilities:

• Review service requests for completeness and gather necessary non-clinical and structured clinical data from physicians and patients.
• Conduct initial screenings for pre-certification requests from physicians and members through calls or correspondence, following established scripts and workflows under clinical staff oversight.
• Prepare, document, and route cases in the appropriate system for clinical review.
• Initiate callbacks and correspondence to members and providers to coordinate and clarify benefits.
• Complete inquiries by initiating callbacks or correspondence to physicians and members to coordinate and clarify case completion.
• Review professional medical or claim policy-related issues or claims in pending status.
• Authorize services based on scripts or algorithms used for pre-review screening upon collection of clinical and non-clinical information.