Health Plan Agent

Job Responsibilities:

1. Conduct Comprehensive Clinical Reviews
Perform pre-service, concurrent, retrospective, and post-service utilization management reviews to assess medical necessity, treatment appropriateness, and coverage eligibility using evidence-based clinical guidelines (e.g., MCG/IQ), benefit plan documents, and regulatory standards (e.g., CMS, HIPAA, NCQA). Escalate complex cases to the Medical Director when required.
    
2. Coordinate Patient-Centered Case Management
Collaborate with physicians, specialists, and multidisciplinary care teams to evaluate diagnoses, outline care plans, and promote high-quality, cost-effective healthcare outcomes. Assist patients in understanding their treatment options and insurance coverage, and facilitate timely discharge planning and follow-up care coordination.
    
3.Evaluate and Validate Medical Claims
Analyze medical records, diagnostic test results, and clinical documentation to determine the eligibility and validity of healthcare claims. Ensure all necessary documents are obtained to support claim determinations, and communicate outcomes effectively to patients, providers, and healthcare partners.
    
4. Ensure Compliance and Quality Assurance
Adhere to organizational protocols, federal and state regulations, and accreditation requirements in all medical review processes. Participate in quality audits, maintain accurate records, and contribute to continuous improvement by identifying trends and reporting data that support care quality initiatives.
    
5. Provide Expert Guidance and Support
Serve as a resource and reviewer for clinical and non-clinical staff conducting authorizations and benefit determinations. Offer mentorship and feedback to junior team members, resolve moderately complex issues independently, and liaise with internal and external stakeholders to address escalated concerns and optimize service delivery.