• Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines. • Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided. • Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines. • Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives. • Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends. • Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization. • Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making. • Please note: This role is focused on clinical case review and does not require after-hour calls, holidays, or weekends.