• Provides active care management, assessing service needs, developing and coordinating action plans in cooperation with members, monitoring services and implementing plans, including member goals • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits • Provides telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment/evaluation • Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans • Ensures coverage for appropriate services within benefit and medical necessity guidelines • Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, etc.) • Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies