• Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME) • Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations. • Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards • Provide notifications to member and/or provider, according to regulatory requirements. • Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed. • May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines. • Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work • Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information • Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.