Case Reviewer (NP/PA) - Ortho Surgery - Elevance Health : Job Details

Receives pre-authorization requests from front-line intake and nurse reviewers. Conducts initial medical necessity clinical screenings. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director. Works closely with Medical Directors to review and make recommendations regarding medical necessity of requested tests, medications, interventional procedures and surgeries. Documents the results of the initial clinical review and determination in the pre-certification system. Conducts initial medical necessity review of out of network pre-authorization requests for services. Conducts review of grievance and appeals requests to provide to Medical Directors. Minimum Requirements:Requires MA/ MS from an ARC-PA (Accreditation Review Commission for the Physician Assistant) accredited program or an ACEN/ CCNE (Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Educatio...Surgery, Medical Director, Nurse Practitioner, Healthcare, Benefits, Compensation