Jefferson

• Shape the future of healthcare delivery across one of the nation’s leading academic health systems. • Lead clinical strategy and utilization management for our integrated health plans and care management programs. • Perform utilization review for requests for services including but not limited to inpatient, outpatient, pharmacy and dental. • Conduct peer-to-peer discussions with providers. • Serve on and support the functions of committees including but not limited to the Utilization Management Committee and Pharmacy & Therapeutics Committee. • Advise the HealthCare Senior Management team regarding the utilization of health care services and interventions to promote the effective delivery of medically necessary services. • Participate and/or lead rounds including but not limited to disease management, care management or admissions. • Provide support for Plan accreditation processes (NCQA), Utilization, Quality and Disease Management programs. • Develop and or revise practice guidelines for acute and chronic care. • Develop and implement policies and procedures required to promote effective utilization management and achieve established targets. • Collaborate with HealthCare Economics and Finance to continuously improve the collection and use of data describing resource utilization and outcomes. • Represent HealthCare Management internally and externally at the direction of the VP Chief Medical Officer. • Develop and implement work plans to optimize appropriate utilization and quality targets as directed by the VP Chief Medical Officer. • Perform other job duties as assigned.

• Provide telehealth-based care in service to patients of the primary care network • Complete outreach to patients who will benefit from a primary care visit • Work closely with primary care and population health teams • Provide patient-centered care with a commitment to excellence in patient experience • Complete annual screenings and/or annual wellness visits with patients as assigned • Complete additional required screenings and care deliverables • Assess chronic disease management needs and assist patients in improving their disease management • Communicate with continuity primary care providers as a key partner in re-engaging and caring for patients

• Reviews payor denials and audits for potential lost revenue • Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity • Functions as a hospital liaison with external third-party payors to appeal denied claims • Works closely with Physician advisor team to facilitate appeals to payors • Monitors and reports payor trends to management team • Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor • Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor • Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials • Contacts insurance companies and conducts appeals via telephone or email • Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights • Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors • Ensures that all appeals are sent to the correct payor within the appeal guidelines • Ensures compliance with regulatory and accrediting requirements • Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor • Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable

• Work collaboratively with the health care team to provide remote and direct supportive care for patients • Promotes quality patient care, comfort, and a safe environment under the direction of a Registered Nurse • Communicates with and supports the interprofessional team, patient, family, and designated care partners • Provides observation for safety of assigned patient • Reports observations of changes in patient condition or behavior to appropriate staff • Completes required reports and documentation • Provides service to the following age population(s) pediatric through frail elderly

• Works collaboratively with the health care team to provide remote and at times direct supportive care for patients who require additional monitoring or assistance • Promotes quality patient care, comfort, and a safe environment under the direction of a Registered Nurse • Recognizes the patients, their family/designated care partner(s) in providing safe, compassionate and coordinated care based on respect for patient's personal preferences, priorities, needs, and cultural beliefs and values • Communicates with and supports the interprofessional team, patient, family and designated care partners • Provides observation for safety of assigned patient • Reports observations of changes in patient condition or behavior to appropriate staff • Completes required reports and documentation

• Responsible for credentialing JMG (Jefferson Medical Group) and JeffCare PHO physicians according to National Committee for Quality Assurance (NCQA) • Perform primary source verification for each provider for initial and reappointments in accordance with contractual requirements • Prepare individual physician credentialing files in accordance with all established standards • Update and maintain demographic and credentialing information in the database • Maintain the integrity of the Delegation Agreement • Work with Quality Assurance Representatives of health plans regarding JMG's and JeffCare PHO's Enterprise credentialing policies and procedures for delegation • Prepare physician welcome letters, expirables, create/run reports and queries as required • Manage and Present at the JeffCare Credentialing meetings (agenda, recordings, minutes, etc.) identifying any issues, concerns and recommendations

• Works collaboratively with the healthcare team to provide remote supportive care for patients • Promotes quality patient care, comfort, and a safe environment • Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson • Recognizes the patients, their family/designated care partner(s) in providing safety and compassionate care • Communicates with the interprofessional team, patient, family, and designated care partners

• Works collaboratively with the health care team to provide remote supportive care for patients • Promotes quality patient care, comfort, and a safe environment under the direction of a Registered Nurse • Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson • Communicates with and supports the interprofessional team, patient, family and designated care partners • Provides remote direct observation for safety of assigned patient • Reports observations of changes in patient condition or behavior to appropriate staff • Completes required reports and documentation

• Serves as the primary regulatory contact for assigned protocols. • Maintains the electronic regulatory binders / files and ensures appropriate version control is in place. • Coordinates submissions to ancillary committees such as Radiation Safety and Institutional Biosafety. • Communicates with the IRB and sponsor on behalf of the study team regarding regulatory management. • Collaborates with the study team and sponsors to finalize documents based on PRMC and/or IRB recommendations. • Prepares and submits study amendments and continuing review applications for PRMC and IRB review. • Prepares regulatory files for auditing and monitoring visits. • Communicating to study teams the importance of adhering to CTO Regulatory processes