1. Clinical Care Coordination: Evaluate patient care needs and coordinate with healthcare providers to ensure quality treatment plans while optimizing member benefits.

2. Utilization Management: Conduct utilization reviews using evidence-based guidelines to determine medical necessity and appropriate care settings.

3. Provider Collaboration: Communicate directly with physicians and specialists regarding patient diagnoses, treatment plans, and timely discharge coordination.

4. Patient Advocacy: Assist patients with healthcare coverage questions and support them in managing complex medical conditions through high-quality care service coordination.

5. Clinical Documentation: Review and analyze medical records, laboratory results, and diagnostic tests to validate claims and ensure appropriate treatment recommendations.

1. At least 3 to 5 years of experience in Utilization and Authorization Management.
2. Alternatively, at least 3 years of experience in a hospital setting.