…claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required + 7+ years experience with Optum Claims

…Benefit questions to improve member experience. + Participates in Quality Improvement projects; Utilization Review ; Individual Drug Profile Review . + Serves

…needs. + Monitors and assesses the use of hospital services by administering utilization review procedures under Federal, State and hospital guidelines. +

…payers to assist in planning and executing a safe discharge. + Collaborate with Utilization Management team on continued stay review . + Educates patients and

…to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patients resources and right to

…functions. + Under direction of supervisor, establish appropriate therapeutic boundaries, utilization of identified clinical resources to review boundaries,

…are in place to achieve desired outcomes. + Collaborates with the Peer Review /PQPR medical staff chair to operationalize assessments of peer review triggers

…care. + Coordinate with Case Management as indicated. + Participates in the review of policy and procedures on an ongoing basis providing evidenced-based revisions

…and evaluating medical records retrospectively for potential quality, safety, and utilization issues by using organizational, national, TRICARE, and URAC standards

…level of recognition for quality in any insurance incentive program + Decrease utilization in various target domains + Setting standards for Faculty and Staff in