This position involves performing medical reviews and utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Performs medical claim reviews and makes reasonable charge payment determinations. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner. May conduct high dollar forecasting research and formulate overall patient health summaries. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures thorough documentation of each determination. Conducts necessary research to make thorough/accurate basis for each determination. Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. Participates in quality control activities in support of corporate and team-based objectives. Participates in all required licenses and certificates.