• Responsible for utilization review calls within BHS • Advocate for BHS patients with insurance and managed care companies • Communicates insurance input to physicians and clinical staff • Assists clinical staff with assessments as needed • Communicates daily with Utilization Review Coordinator • Understands health care benefit plan provisions and managed care contracting

• Perform review of a variety of routine and complex analytical analysis experiments conducted on pharmaceutical and biopharmaceutical compounds. • Ensure analyses are following validated or experimental analytical procedures. • Compare results to methodology, protocol and product specifications, SOPs acceptance criteria, and GMP. • Review data entered into databases and reports. • Monitor the quality of the laboratory data. • Evaluate laboratory data for compliance with analytical methods, client directives, and SOPs. • Review sample results for scientific soundness, completeness, and accurate representation of the data. • Communicate with laboratory staff to proactively maintain the quality of laboratory documentation. • Deliver review findings noting deficiencies within the analytical data or reports in a clear and concise manner. • Escalate significant deficiencies to the project leader or supervisor for assessment. • Facilitate conversations with lab staff on best documentation practices and addressing quality findings. • Advocate for quality and review process changes. • Identify and support process improvement initiatives.

• Performs review of a variety of complex analytical analysis experiments that are conducted on pharmaceutical and biopharmaceutical compounds in various formulations and/or biological matrices. • Possess a thorough understanding of laboratory procedures and can reliably conduct routine, non-routine (method establishment), and complex analytical data review ensuring scientific soundness and adhering to method validation. • Ensures analyses are following validated or experimental analytical procedures, and compare results to methodology, protocol and product specifications, Standard Operating Procedures (SOPs) acceptance criteria, and Good Manufacturing Practices (GMP). • Reviews data entered into databases and reports and monitors the quality and scientific soundness of the laboratory data. • Performs complex analytical data review, evaluating laboratory data for compliance with analytical methods, SOPs, client directives and scientific soundness. • Trains new Data Reviewers and laboratory staff in basic and complex analytical data review. • Mentors junior data review staff in review process. • Identifies and drives process improvement initiatives.

• Prospectively review all OASIS assessments to ensure appropriateness, completeness, and regulatory compliance. • Evaluate OASIS data for internal consistency, accuracy, and alignment with patient condition and care delivery. • Utilize OASIS variation, validation, or alert reports to identify potential data integrity concerns. • Ensure documentation supports accurate clinical representation and compliant reimbursement. • Partner with clinicians and agency staff to clarify documentation discrepancies or data integrity issues. • Provide guidance to clinicians on appropriate corrections in accordance with agency policy and regulatory standards. • Support education and reinforcement of best practices related to OASIS completion and assessment accuracy. • Review visit utilization for alignment with patient condition, plan of care, and clinical guidelines. • Identify and report potential underutilization, overutilization, or financial risk to the Coding and OASIS Manager, Clinical Manager, or designee. • Escalate trends that may impact reimbursement, outcomes, or compliance. • Identify and communicate problematic trends or recurring issues identified through OASIS review. • Participate in Quality Improvement and Corporate Compliance initiatives as assigned. • Assist with additional chart audits or documentation reviews as needed. • Maintain current knowledge of OASIS standards, regulatory changes, and industry best practices. • Demonstrate and uphold CAPLICO values in all interactions and work practices.