• Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health). • Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services. • Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care. • Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment. • Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings. • Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight. • Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.