• Performs a clinical review and assesses care related to mental health and substance abuse • Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate • Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate • Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria • Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning • Analyzes BH member data to improve quality and appropriate utilization of services • Provides education to providers members and their families regarding BH utilization process • Interacts with BH healthcare providers as appropriate to discuss level of care and/or services • Engages with medical directors and leadership to improve the quality and efficiency of care • Formulates and presents cases in staffing and integrated rounds • Performs other duties as assigned • Complies with all policies and standards.

• Deliver proactive coding education through newsletters, scorecards, and presentations, covering CPT (E&M, modifiers), ICD-10-CM, HCPCS, Risk Adjustment, payer requirements, and rejection resolutions. • Lead onboarding and compliance training for all employed Physicians/APPs, including Locum Tenens, residents, and students, ensuring documentation accuracy from the start. • Provide individualized documentation feedback by reviewing new clinician records and conducting spot checks, escalating non-coding issues to appropriate teams. • Serve as the primary contact for coding inquiries, coordinating with internal teams to resolve complex issues such as NCCI bundling and high-complexity charge edits. • Monitor Epic work queues (charge review, follow-up, claim edit) to ensure timely and accurate charge submissions and reduce claim denials. • Collaborate across departments—including CMOs, Clinical Informatics, Risk Adjustment, and Population Health—to enhance documentation practices and system optimization. • Participate in specialty and department meetings, identifying trends and delivering targeted education to improve coding and documentation accuracy. • Refine Epic documentation tools, including templates, order entries, diagnosis lists, and SmartSets/SmartPhrases, to improve efficiency and accuracy. • Ensure compliance with regulatory standards, including Medicare, Medicaid, and AHIMA’s Standards of Ethical Coding, while maintaining expert knowledge of evolving policies. • Promote a culture of ethical coding and continuous improvement, supporting clinicians with timely updates, feedback, and education to ensure accurate reimbursement and compliance.

• Facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation • Collect and assess patient information pertinent to patient’s history, condition, and functional abilities • Develop a comprehensive, individualized care management plan • Link clients with appropriate providers and resources throughout the continuum of health and human services and care settings • Ensure that the care provided is safe, effective, client-centered, timely, efficient, and equitable • Interact with other PacificSource personnel to assure quality customer service is provided • Act as an internal resource by answering questions requiring medical or contract interpretation

• Collaborate closely with physicians, nurses, social workers, and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services • Assess the member’s specific health plan benefits and additional resources available • Provide utilization management (UM) services which promote quality, cost-effective outcomes • Facilitate outstanding member care using fiscally responsible strategies • Collect and assess member information pertinent to member’s history in order to promote wellness • Coordinate necessary resources to achieve member outcome goals and objectives • Accurately document case notes and letters of explanation