Your Work In this role, you will: Complete assigned clinical reviews (preservice requests, Concurrent Review, Provider Claims Disputes, pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for the membership as well as other lines of business, including Medicare

Partner closely with the Sr. Medical Director, Utilization Management to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the membership

Support Sr. Medical Director, Concurrent Review in coordinating the care of membership, to provide access to high-quality health care to these members

Support Sr. Medical Director, Concurrent Review in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver

Collaborate with teams in the implementation and operation of assigned initiatives

Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program

Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class

Participates actively assigned Committees

Abides by all applicable laws and regulations as mandated by state and federal laws

Any other assigned duties