Knowledge of National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), Medicare, Group/Independent Physician Association (IPA), capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines. Educates and interacts with network and group providers regarding utilization practices, guideline usage, and effective member management; provides clinical representation for business presentations in partnership with provider relations.