• Provide national medical oversight of all utilization management functions, ensuring alignment with organizational goals and compliance with regulatory and accreditation standards. • Serve as a clinical resource and subject matter expert to utilization management nurses, case managers, and other clinical staff. • Conduct peer reviews and clinical reviews for medical necessity determinations, complex cases, and high-cost claims. • Participate in inter-rater reliability assessments to ensure consistency and accuracy of medical review decisions. • Collaborate with Quality and Risk Adjustment teams on MRA and quality education initiatives to enhance outcomes and compliance. • Partner with leadership to develop and refine utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual). • Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care. • Support physician engagement, education, and alignment through clear communication and collaboration with internal and external providers. • Participate in ongoing evaluation and improvement of UM operations, including metrics monitoring and performance review. • Perform other duties as assigned to support clinical and operational initiatives.