Traffic control of healthcare.
2 AI translations · Healthcare / Health Plans
UM nurses review inpatient cases daily: applying InterQual or Milliman Care Guidelines (MCG) criteria to determine medical necessity for continued stay, coordinating with attending physicians on discharge planning, identifying patients who no longer meet inpatient criteria (and facilitating transition to observation, SNF, home health, or outpatient), and documenting the clinical rationale for each continued stay day. You manage the appeal process when a payer denies continued stay. LOS management directly impacts hospital finances (DRG-based reimbursement doesn't increase with extra days), patient throughput, and quality metrics (excess days are associated with complications).
As a health plan, you review prior authorization and precertification requests from providers: evaluating whether proposed services meet medical necessity criteria per your medical policy, clinical guidelines, and coverage determinations. You apply medical policies (often hundreds of policies covering specific procedures, drugs, devices, and services), manage the clinical review queue, issue approvals, denials, and requests for additional information, and process appeals (including external independent review). Turnaround time requirements (urgent vs. standard, state-specific timelines) create operational pressure. CMS and state regulatory focus on prior auth burden is intensifying.