Knowledge of Managed care assessing, planning, implementing, monitoring, and evaluating actions required to meet the client's health and human services needed.Established relationships and effectively engaged with members/providers through telephonic communication to obtain necessary information and facilitate care in multiple care settings.Managed Medicare/Medicaid and Ambetter. Completed clinical reviews and applied medical policies & procedures along with determination of medical necessity and level of care reviews for requested services using clinical judgment and redirecting to Medical Directors for review depending on case findings, educate providers on utilization and medical management processes. Expert areas: HH/PDN, SST, DME, Ambetter, Therapy dept, D/C planning, Inpatient (IPE’s), Denial process, Peer to Peer processes, Investigating formal & informal complaints, Auditing and medical records review. Proven commitment to timeliness, follow-up, effective prioritization, accuracy and attention to detail with audits at 98% accuracy rate.