Interprets relevant clinical criteria and/or medical policy/benefits for an identified case. Determines when to consult appropriate provider or practitioner and to review case with medical Director for additional action.
Ensures accurate and complete documentation of required information to meet risk management, regulatory, and accreditation requirements.
Prepares and reports business information to internal and external constituents. Consults with the constituents on solutions to business issues.
Identifies trends involving clinical issues and reports/recommends solutions to senior management and others.
Conducts audits and/or assessments to determine compliance with guidelines. Identifies gaps and May assist in the development/re-evaluation of corrective action plans.
