and National Committee for Quality Assurance ( NCQA ) certified medical review companies are consulted on a case-by-case basis for questions or appeals that require same specialty review .
Utilization management functions performed by Healthcare Utilization Management consist of authorizations , pre-certification , concurrent review , discharge planning and large case management . Healthcare Utilization Management is staffed by Nevada licensed Medical Directors , registered nurses , and pre-certification specialists .
Information Resources
The Information Resources Department provides systems analysis , technical support , computer operations , web site development and reporting and analysis to meet the informational needs of Hometown Health . Information Resources also assists in maintaining the security and integrity of Hometown Health information .
Network Services
The Network Services Department includes ; contracting , credentialing , and provider relations . The staff develops and maintains the participating provider networks throughout Nevada .
Pharmacy
The Pharmacy Department coordinates administration of the pharmacy benefit and medical-drug benefit for the members of Hometown Health and Senior Care Plus . The department works closely with the Pharmacy Benefit Manager ( PBM ), providers , and the Hometown Health staff to administer the benefit within the Formulary .
Provider Relations
The Provider Relations Department , a division of the Network Services Department , offers education , training and guidance to our provider network . In addition , the department also leads the timely and satisfactory investigation and resolution of provider inquiries related to product , reimbursement , billing requirements and claims submission .
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