Assist the Medical Review team by providing education and identifying training opportunities during mentoring process and participate in on-site audits and ALJ hearings as needed. Analyze, evaluate, and conduct medical review investigations, studies, and data review in accordance with the UPIC policies and contract responsibilities. Conduct in depth claim review of providers suspected of fraud.
Provide quality improvement focused work for all delegated entities and support ACO quality reporting to improve patient health outcomes. Conduct proactive patient outreach and address quality gaps by educating them on preventative care. Leverage quality related resources and communicate performances and improvement strategies with customers.
Acts as a liaison between patients, providers, and insurance companies to ensure appropriate data collection, compliance with third party payers and federal and state regulations. Obtains benefits, eligibility and preauthorization, and acts as a financial counselor when explaining insurance and payment options.