Senior Specialist guiding field monitoring for clinical trials at Edwards Lifesciences

The primary role involves auditing medical records to detect inappropriate billing practices by extensively reviewing claims data, medical records, and various policies, and then recommending appropriate next steps. This includes performing retrospective and prepayment reviews to identify potential fraud, abuse, and inappropriate billing patterns, and preparing summary findings for providers.

The Case Management Coordinator provides active care management, assesses service needs, develops action plans in cooperation with members, and monitors services to ensure alignment with member goals. This role involves performing medical or behavioral review/authorization, ensuring coverage within benefit and medical necessity guidelines, and serving as a member advocate through ongoing communication and education.

The specialist will conduct detailed secondary patient assessments via intake calls to evaluate potential eligibility for clinical trials across various therapeutic areas. This involves reviewing medical history and diagnoses against study inclusion/exclusion criteria to ensure candidates meet requirements before site visits.