• 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 • Engages with medical directors and leadership to improve the quality and efficiency of care • Formulates and presents cases in staffing and integrated rounds

• Provide clinical expert knowledge and clinical guidance to Quality Specialists to understand the nature of complaints and possible health risks. • Provide clinical expert knowledge, clinical data insights and risk evaluation guidance to Quality Specialists to support complaint assessment, trend identification, regulatory decision-making and potential health risk evaluation within Structural Heart therapies. • Analyze and interpret aggregate complaint, clinical and post-market data for a specific product line, business unit, regulatory submissions, regulatory agency requests and management reports, including trend identification, visualization and ad hoc analytical summaries. • Provide clinical input to Product Risk Assessments (PRA), utilizing complaint data, clinical trends and predictive risk indicators where appropriate. • Support the development and use of AI-enabled tools to enhance complaint evaluation, signal detection and quality decision-making. • Review and interpret relevant imaging information in support of complaint investigations, product quality assessments and risk evaluations. • Develop data visualization tools and dashboards to support quality monitoring, trend detection and management decision-making. • Support Product Safety in development of clinically based training materials and educate complaint staff to understand the medical aspects of complaint information and associated procedures including health risks. • Provide medical/clinical guidance and final direction to complaint staff related to event interpretation, event investigation, proper coding, required regulatory reporting, and complaint closure. • May review complaint conclusions/closure statements and/or customer letters. • May provide training to complaint staff on patient anatomy and medical conditions, products and procedures, and internal policies and procedures. • Provide support in complaint data and relevant clinical information for regulatory submissions or regulatory agency requests. • Mentor, coach, and provide training for other Clinicians Quality Compliance and Quality Specialists. • Obtain and evaluate information from clinical specialists, sales staff, physicians, nurses and other hospital staff/customers, as needed to support complaint investigation and drive towards resolution. • Support Product Safety to maintain Decision Rationale Matrix to guide complaint staff and provide final direction on reporting decisions.

• Provide individual, family, and group therapy to children with severe emotional disturbance and their families. • Complete clinical assessments, develop diagnoses, and create person/family-centered treatment plans. • Maintain a minimum of 6 service hours per family per month (at least 4 must be face-to-face). • Ensure timely completion and updating of CAFAS/PECFAS and MichiCANS assessments. • Keep accurate documentation in both electronic and paper charts, including progress notes and treatment plans. • Participate in supervision and team meetings to review client progress and strategize support. • Provide 24/7 crisis intervention support on a rotating basis. • Ensure compliance with funder and agency documentation standards. • Approve and deliver only medically necessary and approved therapeutic services. • Apply trauma-informed and co-occurring disorder care practices. • Must be willing to assist individuals with trauma-related issues. • Travel throughout the designated area using a personal or agency vehicle to deliver community-based services.

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and NCQA standards • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal • Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards • Communicates with members, providers, facilities, and other departments regarding appeals requests • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices • Performs other duties as assigned • Complies with all policies and standards