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Performs clinical evaluations on medical claims to ensure documentation substantiates the need for employee absence. Acts as a clinical resource for claims examiners and provides guidance on medical management and claim decisions.
The Senior Director leads analytic service delivery by aligning strategic objectives with tool development and managing cross-functional analytic teams. They partner with clinical and business leaders to drive data-informed decision-making, performance improvement, and value realization across the enterprise.
The Clinical Pharmacist will support Medicaid prior authorization processes by applying evidence-based clinical guidelines and formulary designs. The role involves reviewing medical records and clinical literature to ensure accurate clinical decision-making within a managed care environment.
Direct and coordinate medical management, quality improvement, and credentialing functions to optimize member care and cost-effectiveness. Perform medical reviews of complex cases and provide leadership for utilization management and regulatory compliance.
Provide clinical supervision and regulatory oversight for Psychiatric Mental Health Nurse Practitioners. Conduct direct patient care including psychiatric evaluations and medication management sessions.
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