…and familiarity with HEDIS measure specifications. * Prior work in utilization management, quality management/ review , accreditation, outpatient clinic setting or

…to join one of our Fortune 500 clients. **Job Summary** The Medical Review and Utilization Management Specialist is responsible for performing medical reviews

…Communicate kept appointments without charges, CME/license/dues annual reports, and monthly slot utilization reports. 2. Quality Assurance: * Review charts for

…ensure effective care coordination + At the direction of the Medical Director, review outcomes and utilization data, including hospitalizations, and use of

…throughout the hospital stay for the appropriate level of care and utilization of resources. The case manager will perform transition care planning activities

…to the appropriate facility and division individuals. + Provides input on the utilization of PLUS and Benchmark; web-based applications used to capture and report

…TRICARE directives, coordinating with the local Medical Home Port (MHP) clinic, utilization and Referral Management policies, and obtains additional clinical data as

…resource referrals as necessary. + Manage assigned case load, assessing utilization of resources and services, identifying patients that require additional

…throughout the hospital stay for the appropriate level of care and utilization of resources. The case manager will perform transition care planning activities

…the clients responses to the plan of care. 11. Performs a patient record review with the collaborating physician in a timely fashion but not less than every