Responsible for the appropriateness and quality of care delivered through SCFHP and for cost-effective utilization of services. Responsible for Medi-Cal, Healthy Kids, and Medicare lines of business. Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations. Reviews that care is consistent with the Plan’s standards of quality. Participates in concurrent review activities of inpatient and long term care plans. Reviews claims that are unusual in cost, volume or scope of services. Acts as liaison between SFCHP and community providers, conferring and meeting as required. Coordinates with Directors of Medical Management and Quality Improvement to provide daily s
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