• Performs data collection and review to identify areas requiring intensive management. Analyzes data collected and prepares reports describing resource utilization patterns. Disseminates information to government members of collaborative teams and multidisciplinary hospital committees.

• Coordinates specialty care referrals. They shall review specialty care referrals for appropriateness, completeness and disposition the referral to the appropriate place of care.

• Serves as functional expert in the area of health benefits and provides health benefits advice to patients.

• Maintains and tracks referral records.

• Participates with referral centers in providing, assessing, and improving a wide variety of customer services/relations.

• Assists in the management of all forms of communication between beneficiaries, referral centers, internal staff and providers, network/outside providers and ancillary healthcare workers.

• Working knowledge of latest versions of office automation software utilized in their area of expertise required; working knowledge of EHR Genesis and Managed Care Support Contractor (MCSC) databases is required.

• Knows and understands the principles of utilization review (UR) and utilization management (UM) and applies knowledge in processing specialty referrals.

• Plans and performs specialty referral reviews IAW established guidelines to provide quality cost-effective care.

• Conducts first level reviews for all referrals to specialty care.

• Acts a facilitator of professional and patient care activities.

• Interfaces with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals.

• Identifies cases that may benefit from alternative levels of care and involves the case manager as needed to provide direction in care management.

• Plans and prioritizes UR activities to ensure identified patient needs are addressed promptly.

• Effectively utilizes information systems to develop, design, analyze, update and record data.

• Facilitates the development and integration of UM review policies and procedures into operations.

• Performs Right of First Refusal coordination of specialty care referrals. Shall review specialty care referrals for appropriateness, completeness and disposition the referral to the appropriate place of care.

• ROFR knowledge in the area of health benefits and provides health benefits advice to patients.

• Maintains and tracks referral records.

As a GiaCare Inc. employee, you may enjoy the following benefits:

• Medical Insurance (GiaCare pays for employee's medical benefits)
• Vision Insurance
• Dental Insurance
• Short-Term Disability Insurance
• Life and AD&D Insurance
• Paid Time Off (PTO)
• 401k (Non-matching)
• Employee Referral Program

*MUST BE US CITIZEN