• Provides administrative oversight to the medical staff • Analyzes medical review utilization data • Researches new medical procedures or technology • Acts as a resource to providers and internal staff on issues concerning medical policies • Writes and revises medical policies • Supports operations in the form of case review on both medical and regulatory matters • Develops claim adjudication criteria for situations requiring medical judgment • Provides input on issues and operational policies, processes, and procedures • Educates staff and medical community on various aspects of medical policy and program administration • Develops and updates medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies • Develops external relationships with the medical community and serves as liaison between these entities and the contractors • Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization • Conducts research into new or controversial medical procedures and technology