• Collect and submit reliable data to the American College of Surgeons (ACS) for the National Surgical Quality Improvement Program (NSQIP).• Review EMR record and surgical logs to abstract the defined clinical data elements and enter them into the ACS NSQIP database.

• Conduct telephonic ED/Inpatient follow up calls.• Complete HRS/HRA screenings.• Manages a caseload of low-moderate risk member.• Monitor and assess caseload of up to 200+ members monthly for disease management.• Identify high risk members and complex cases that require case management by an RN/SW.

• Perform Health Risk Assessments (HRAs) telephonically and LTC visits face to face within 60 days of enrollment.• Assist field based case management team with members and provider calls, assessing the needs and provide timely follow up.• Accurately create and document assessments, notes and reviews in the case management system.• Manage the fax boxes and submit pertinent information to the field based case management team, health services leadership team and the medical directors in a timely manner.• Perform weekly chart audits/performance evaluations for nurse management staff.• Facilitate the request for prior authorization of inpatient and outpatient services, ensuring timely and accurate responses in compliance with state and federal guidelines.

• Perform pre-admission, admission, and concurrent quality/utilization review of medical services rendered through regular review of patient records as well as consultation with providers.• Authorize hospital stays according to guidelines and in accordance with ACCESS’s Utilization Committee criteria. • Consult with the Medical Director for quality/utilization problems.• Assures timely and appropriate discharge planning of hospitalized, nursing home, and home health care patient through consultation with physicians, ancillary service providers, and contact with patients and/or families as indicated.• Maintain regular contact with appropriate hospital departments and providers to identify and facilitate correct Primary Care Physicians (PCPs) and transfer out of plan admissions to in plan facilities.• Recognizes quality of care issues according to acceptable clinical standards and reports issues to the QM manager and/or Medical Director as indicated.• Review and monitor outpatient referral medical services to maintain cost effective resource utilization management.• Provide ongoing QM/UM education to the PCPs as well as the clinical staff.