• Review medical records and follow stringent
protocols to determine whether patients
meet the standards for insurance
reimbursement.
• Clinical review for medical necessity of
identified claims.
• Documentation of clinical rationale
supporting findings of the review.
• Apply clinical judgment, honed over years in
acute care settings, to make responsible
decisions that promote appropriate records
review and applications usage while keeping
resources available to those most in need.
• Review and validate all information pertaining
to the claim.
• Comply with procedures, regulations, and
rules in maintaining medical records.
• Interacts on a continuous basis with other
departments by directing activities towards
positive outcomes