Allied Health Professional – Full-Time Position

1. Provide Expertise in Medical Claim Validation & Utilization Review
Utilize your in-depth knowledge to conduct comprehensive medical claim assessments and utilization reviews, ensuring patients receive appropriate care. You’ll work closely with healthcare providers to determine claim eligibility, validate medical necessity, and ensure all services are cost-effective, high-quality, and in line with medical guidelines.

2. Collaborate with Medical Professionals to Optimize Patient Outcomes
Act as a key liaison between patients, healthcare providers, and clinical teams, reviewing patient diagnoses, treatments, and clinical documentation. You’ll guide providers to make timely, medically justified decisions, ensuring that the care delivered aligns with best practices for optimal patient outcomes.

3. Lead in Efficient, Accurate Communication with Healthcare Providers & Patients
Take charge of inbound and outbound communication, efficiently handling calls and emails with patients and healthcare providers to confirm medical claims, validate eligibility, and review patient treatments. Provide clear and concise updates regarding claim statuses and patient care, ensuring a smooth process for all parties.

4. Ensure Compliance with Healthcare Regulations & Policies
Review and assess medical claims, patient records, and treatment plans while adhering to federal, state, and company-specific regulations. Maintain strict confidentiality and ensure compliance with HIPAA, CMS, NCQA/URAC standards. Your attention to detail and understanding of policies will guarantee the highest level of accuracy and timeliness in all reviews and decisions.

5. Drive Continuous Improvement in Medical Management & Clinical Workflow
Take initiative in improving clinical workflows and streamlining processes by collaborating with research teams, healthcare professionals, and specialists. By analyzing data and providing actionable insights, you’ll help optimize member benefits and ensure that the delivery of healthcare services is both efficient and effective.