• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals • Documents decisions using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination • Monitors process's timeliness in accordance with contractor standards • Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines • Utilizes allocated resources to back up review determination • Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process • May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs • Performs screenings/assessments and determines risk via telephone • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services • Provides education to members and their families/caregivers • Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each • Conducts research necessary to make thorough/accurate basis for each determination made • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations • Participates in quality control activities in support of the corporate and team-based objectives