• Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources • Learns Medicaid requirements and understands how to operationalize this knowledge in their daily work in their assigned cluster • Work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management, with clinical scenarios arising from outpatient or inpatient environments • Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, and in some instances, these may require conflict resolution skills • May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes and a focus on collaborative business relationships, value-based care, population health, or disease or care management • Supports Humana values including working collaboratively on a team throughout all activities • Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage