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What You’ll Be Doing:
- Complete timely review of healthcare services using appropriate medical criteria to support determinations.
- Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards and Guidehealth policies.
- Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Clinical Consultation & Collaboration:
- Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
- Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
Guidehealth
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.