• Support clinical review activities, including all of the following: pre-service, post-service, concurrent facility-based care, and transitions between levels of care. • Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion, or network structure. • Use clinical expertise to support claims review decisions, including level of care, pricing and complexity assessment, dependent disability status and by report procedure payment determinations. • Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determination and collect additional clinical history in each case. • Consult with nursing and other clinical staff to assess and explore care options for members enrolled in clinical programs such as disease management, case management, and care transition management. • Participate in the development, annual review, and approval of company medical review criteria as a member of the Premera Medical Policy Committee. • Leverage clinical knowledge and expertise to support ongoing education for all clinicians involved in medical review. • Provide professional advisement to all requests for consultation from within Premera Blue Cross and with contracted practitioners/ facilities. • Participate in Inter-Rater Review process to ensure consistency in clinical decision-making. • Understand and abide by applicable federal, state, and accreditation regulations and standards. • Complete all professional continuing education requirements and participate in ongoing education/ training as appropriate.