• Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals • Discuss cases with physician providers (Peer to Peer) • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests • Collaborate with Case Managers to provide support and guidance on cases needing physician assistance • Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review • Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary • As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies • Participate in the development and review of Medical and Pharmacy policies as assigned • Support the organization as a subject matter expert • Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy • Perform other duties as assigned and needed by the organization