• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals • Documents decisions using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination • Monitors process's timeliness in accordance with contractor standards • Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines • Utilizes allocated resources to back up review determination • Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process • May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs • Performs screenings/assessments and determines risk via telephone • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services • Provides education to members and their families/caregivers • Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each • Conducts research necessary to make thorough/accurate basis for each determination made • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations • Participates in quality control activities in support of the corporate and team-based objectives

• Conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements • Daily interactions with UM Support staff and providers to ensure clinical information and support are available and applicable to the review process • Appropriate prioritization of authorization requests • Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies • Concurrent review of Behavior Health Services

Role Description As a Paediatric Healthcare Assistant at Komplex Care, you’ll be providing care and support to a client, whose individual needs includes: - PEG - Brain Injury - Developmental Needs - Epilepsy - Palliative Care - Personal Care - Medication Administration Qualifications - Level 2 or 3 NVQ/QCF in health care is desirable. Requirements - Existing work authorisation for the UK. Benefits - Pension Scheme for long-term security. - 24/7 GP access for you, your partner, and children (up to 18). - Free mental health support for you, your partner, and children (up to 18). - Life insurance for peace of mind when it matters most. - Home life advice line for everyday guidance. - Career development opportunities. - Wellbeing videos and guided meditations. - Earn points for staying active. - Vouchers for Amazon, Tesco, Nike and more. - Up to 33% off gym memberships. - Employee of the Month recognition with a £50 voucher.

Role Description The Medical Support Specialist, whom is either a Medical Assistant or EMT, will provide administrative support to the medical team. - Providing excellent customer service - Scheduling patients for appointments and reviewing medical history - Recording patient information into medical records - Maintaining accurate records - Completing administrative tasks - Performing all other duties and tasks as assigned Qualifications - Minimum three (3) years of experience as a Medical Assistant or EMT - Must possess valid BLS (CPR) certification - Knowledge of medical terminology and clinical procedures - Knowledge of HIPAA compliance - Proficiency in Microsoft Office 365 and Adobe - Excellent interpersonal and communication skills - Ability to remain calm and professional in stressful situations - Ability to work independently and as part of a team Requirements - Valid Medical Assistant (MA) certification / license or EMT license (preferred) - Experience working in an office clinic or similar healthcare setting (preferred) Work Environment - Employees may be exposed to extreme cold or hot weather conditions, fumes, or airborne particles, toxic or caustic chemicals, and loud noise. Physical Requirements - Employees may be required to remain in a stationary position, stand, push, pull, climb, kneel, crawl, balance, squat, bend, and reach during shifts. - Employees may be required to use gear to move items around, including, but not limited to, carts and dollies. - Employees may also be occasionally required to lift and/or move up to 49 pounds.