Excellus Health Plan Inc.
Latham, NY, USA
Job Description: This position is responsible for coordinating, integrating, and monitoring the utilization of behavioral health (BH) or physical health (PH) services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs. Participates in rotating on-call schedule, as required, to meet departmental time frames. Per department needs, may be responsible for additional hours. Essential Accountabilities: Level I Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members' behavioral health conditions, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates. May perform clinical review...