• Conducts reviews of clinical interactions and clinical documentation including reviews of case management records and provider treatment records • Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting • Interacts with multiple stakeholders internally and externally • Provides clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents related to clinical services • Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements • Reviews provider treatment records against clinical and procedural established standards • Conduct ongoing activities which monitor established quality of care standards in the participating provider network and for care managers • Conducts reviews of Quality of Care and Critical/Adverse Incidents • Evaluates level of patient safety risk and need for follow-up actions per policies • Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services • Prepares monthly performance reports with assistance from Reporting and Analytics unit • Presents findings at provider and customer meetings as needed • Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers. • Responsible for auditing as well as validating internal audit results and/or corrective action plans.