• Monitor and manage participant appointment requests and schedules • Notify participants, caregivers, and POAs of scheduled appointments • Complete authorizations and referral documentation accurately • Coordinate scheduling, re-scheduling, and follow-up for outside appointments, labs, and imaging • Enter encounters for outside appointments in the medical records system • Process invoices and documentation for proper routing and payment • Answer phone calls and respond professionally to participant and referral inquiries • Communicate clearly with healthcare providers and staff regarding scheduling updates • Participate in team meetings and quality improvement initiatives • Adhere to established procedures and ensure all work is accurate, consistent, and complete

• Conduct all mandatory case review and quality assurance activities • Assure the efficiency of the case review process • Communicate with and support physician reviewers • Edit documentation for internal and external dissemination • Develop and maintain working relationships with community agencies

• Conduct an initial assessment of documentation from both the initiating and responding parties. • Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. • Follow procedures to obtain the appropriate documentation. • Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. • Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. • Collaborate with the legal team to facilitate resolution of disputes. • Draft professional determination correspondence. • Perform quality assurance checks on determinations according to Federal or State guidance. • Audit and analyze patient records to ensure appropriate determination. • Stay current with regulation changes and perform research on a case-by-case basis. • Deliver high-quality, professional determinations free of grammar and spelling errors. • Amend reports with additional clinical information when necessary. • Participate in an interdisciplinary health care team to achieve positive outcomes.

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care. • Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria. • Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns. • Uphold the highest standard of clinical integrity, neutrality, and objectivity.