Clinical Support

The Clinical Support Unit’s responsibilities are:

  • To provide support to all clinical aspects of the Cardinal Innovations Healthcare Solutions operations
  • To ensure Clinical Operations compliance with all internal quality initiatives as well as NCQA
  • To ensure compliance with State and Medicaid operational processes and reporting requirements

The main functions of this unit include:

Enrollment & Eligibility

      • Check consumer eligibility
      • Review and approve provider submitted Enrollments
      • Maintain IRPS Compliance
      • Monitor NCTOPPS
      • Ensure data integrity related to Target Populations
      • Research Medicaid loss reports, missing data reports and duplicate client reports
      • Coordinate research on claim kick outs and denials and ensure that corrections are submitted

Appeals & Data Analysis

      • Gather, analyze and report clinical data to maintain compliance with Agency, NCQA, State, and/or Federal Performance Indicators
      • Utilize data to assist Cardinal Innovations Healthcare Solutions in service delivery determinations
      • Monitor and enhance the Cardinal Innovations Healthcare Solutions computer system to maintain compliance with local, state and federal regulations
      • Coordination of the Appeal Processes
      • Convey adverse decisions on Medicaid and State funded service requests
      • Monitoring and trending of Denials and Appeals
      • Coordination of Provider Review and Determination Process to address requests regarding claims denial (less than $50,000) or authorization denial