Medical Claims Review: Reviewing medical claims submitted by policyholders or healthcare providers to ensure they meet coverage criteria, are medically necessary, and comply with policy terms. Utilization Management: Assessing the appropriateness and efficiency of medical treatments and services provided to policyholders. Utilizing evidence-based guidelines and clinical protocols to evaluate treatment plans and ensure optimal utilization of healthcare resources. Pre-authorization: Reviewing requests for pre-authorization of medical procedures, treatments, or medications to determine medical necessity and approve coverage before services are rendered. Medical Consultation: Providing medical expertise and guidance to claims adjusters, underwriters, and other insurance professionals on complex medical issues, treatment options, and healthcare best practices. Health Education: Developing and delivering health education materials and programs to policyholders on topics such as preventive care, chronic disease management, and lifestyle modifications to promote overall wellness and reduce healthcare costs. Clinical Review: Conducting clinical reviews of policyholders' medical records, diagnostic tests, and treatment plans to assess medical necessity, appropriateness of care, and compliance with clinical guidelines. Case Management: Providing support and coordination for policyholders with complex medical needs or chronic conditions. Collaborating with healthcare providers to develop and implement care plans, monitor progress, and facilitate access to necessary services and resources. Medical Policy Development: Participating in the development and revision of medical policies, coverage guidelines, and reimbursement criteria based on clinical evidence, regulatory requirements, and industry standards. Quality Improvement: Participating in quality improvement initiatives aimed at enhancing the quality, safety, and effectiveness of healthcare services. Identifying opportunities for process improvements and implementing strategies to optimize patient outcomes. Compliance and Regulatory Affairs: Ensuring compliance with healthcare regulations, accreditation standards, and insurance industry guidelines. Staying informed about changes in healthcare laws and policies that may impact insurance coverage and reimbursement practices.