CommunityCare

Leads governance, audit readiness, and performance improvement across Physical, Behavioral, and Pharmacy Utilization Management and Appeals and Grievances. Oversees internal and delegated entity auditing, corrective action plans, and the alignment of policies and procedures to meet regulatory requirements.

The role focuses on optimizing medication use and ensuring regulatory compliance through the review of prior authorization requests for specialty medications. It involves developing evidence-based clinical criteria and supporting medication therapy management programs.

Responsible for the clinical review of utilization requests and the implementation of care coordination for high-risk and institutionalized populations. Collaborates with providers to determine medical necessity and ensure appropriate service delivery across the healthcare continuum.

Responsible for the clinical review of utilization requests and the implementation of care coordination for high-risk and institutionalized members. Collaborates with providers to ensure medical necessity and appropriateness of services across the healthcare continuum.