rena whorley

Responsible for managing a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to: Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting. Utilizes the applicable medical policy and industry standards, accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources. Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Hires, trains, coaches, counsels, and evaluates performance of direct reports