Responsible to collaborate with healthcare providers and care managers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.


Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of outpatient waiver services, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.


Primary duties may include, but are not limited to: precertification review, collaboration with care managers for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, state recommended guidelines, and contracts.


Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.


Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.


Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Ensures consistency in benefit application.


Participates in intradepartmental teams, projects and initiatives.


Requires current active unrestricted RN license to practice as a health professional within the scope of practice in Virginia and minimum of 2 years acute care clinical experience. For URkills, facilitation skills, and analytical skills. LTSS experience highly desired.AC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving s