Healthcare Operations Representative

Key Responsibilities:
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.

Qualifications:
- Graduate of Allied Sciences, Social Sciences, or related fields (Physical Therapy, Rad Tech, Pharmacy, Psychology, Medical Tech, Nutrition & Dietetics, etc.)
- Active PRC License is required
- Minimum 1-year experience in direct patient care (Long-Term Care, Home and Community-Based Services, Hospital Settings, or Case Management)
- Experience with managed care organizations, Medicare/Medicaid processes preferred
- HIV counseling experience required
- Strong communication skills and problem-solving abilities
- Ability to analyze clinical information and determine appropriate actions