Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related to clinical initiatives such as health fairs and communicate with agencies and providers.Perform quality on site reviews of delegated entities, physician office/clinics, resolve quality issues, generate written summary of findings and follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC).Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues.Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activitiesFunction as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance.Schedule and chair meetings with delegated entities in accordance with their contract.Gather data and compile various utilization and quality improvement reports.Develop and implement Corrective Action Plans.Recommend changes/enhancements to the Quality Improvement policies and procedures.Identify best practices, research new processes and recommend program enhancements.Coordinate QIC activities and monthly meetings.Oversee the enforcement of contract terms regarding data submission for delegated entities.Participate in the development of reporting and data outcome reports.

Review and coordinates specialty care referrals to ensure completion of associated daily functions and/or takes appropriate actions. Advises patient regarding treatment options, travel requirements, and assist to answer patient questions at specific treatment facilities and documents in chart. Ensure referral process to selected treatment facilities is in progress. Assists patients with process of the Right of First Refusal determinations for specialty care and sever as functional expert in the area of health benefits available to the patient. Provides patients with referrals to network providers and tracks all referral results/outcomes. Provide information to patient network provider for redirected care and documents services performed. Maintain and track referral records. Review all communications from Network providers and patients. Function as a single point of contact for all involved in patient care through follow-up with patient Network providers regarding possible services. Identifies cases that may benefit from alternative levels of care and seek involvement from case manager, team members, all providers, and ancillary health care workers, as needed to provide direction in patient care.

Access and review medical records via online systems against HEDIS Technical Specifications, Access member record in HEDIS software, Document medical record review results in online tracking system, summarize DRG disputes in and cites official coding guidelines, navigate through multiple vendors systems i.e. (recordflow, Outcomes, Optum)