Basic Function: This position is responsible for performing discharge care coordination and review activities for determining efficiency,effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and NetworkManagement Divisions. Review service requests, collect clinical and non-clinical data, verify eligibility, determine benefitlevels in accordance to contract guidelines, conducting initial and concurrent review, prepare reports on quality of care,identify and report cases, and provide information regarding utilization management requirements and operational.
procedures to members, providers, and facilities.



Essential Functions:

Determine efficiency, effectiveness, and quality of medical/surgical services, including appropriateness of hospital admissions, length of stay, level of care and discharge planning.

Serve as liaison between providers and Medical and Network Management Divisions. <...