Review and sign off on proposed pharmacist denials for preservice outpatient medication requests, after review of medical records when provided Conduct coverage review on some medical cases, based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in

Participates and assists in the preparation of quality committees, performance improvement projects, and other aspects of the Quality Assessment and Performance Improvement (QAPI) program as assigned Collect information based on applicable standards, state/federal or other regulations, internal requests, or project assignments Leverages available resources to improve qual

Assess, plan, and implement care strategies that are individualized by the member and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for socia

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Co

Provide a complete continuum of quality care through close communication with members via in person or on phone interaction Support members with condition education, medication reviews, and connections to resources such as Provider Services, Private Duty Nursing, DME, and supplies Assist members with the transition from a care facility back to their home This role involve

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Co

Ensuring delivery of cost effective quality care that incorporates recovery, resiliency and person centered services Responsible for Level of Care guidelines and utilization management protocols Responsible for oversight and management, along with the Clinical Director and Clinical Program Director, utilization review, management, and care coordination activities Provide