- Conduct timely medical necessity determinations for inpatient admissions and post-acute settings including SNF, IRF, LTACH, and Home Health.
- Assess the appropriateness of acute care services using evidence-based guidelines like MCG/InterQual and CMS criteria.
- Lead peer-to-peer discussions with attending physicians to clarify documentation and support appropriate levels of care.
- Serve as the primary physician reviewer for escalated or complex utilization management cases.
- Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in committee meetings.
- Maintain documentation compliance according to NCQA and CMS requirements and support audit preparedness.
- Identify care patterns to support interventions that reduce unnecessary admissions or extended stays.