• Performs pre-service and concurrent reviews of requested services within specified department timelines. • In-Patient reviews include Acute Facilities and Skilled Nursing Facilities. • Out-Patient reviews include service authorizations and home health care. • Applies clinical knowledge for the interpretation and evaluation of clinical data to ensure compliance with established criteria. • Reviews authorization requests for services according to adopted Plan and InterQual criteria. • Reviews questionable cases with facility team members and the Medical Director to assess if care requested meets medical necessity criteria. • Documents denial process and provides timely provider and member notification following specified timelines and department protocols. • Initiates early discharge planning, incorporating transition of care plans, with facility team members and plan's primary care providers. • Initiates and coordinates facility transfers, incorporating transition of care plans. • Coordinates with appropriate state representatives and internal team(s) on member and provider appeals. • Makes appropriate referrals to quality improvement, behavioral health, and complex case management. • Completes retrospective chart reviews and pended claims reviews as requested. • Maintains strong collaborative working relationships with specialty, ancillary, and primary care providers. • Documents completely and accurately within an electronic clinical record. • Provides education on the utilization management process to members and providers as requested. • Ensures utilization management program compliance and successful reimbursements by understanding applicable contract terms. • Participates in care management as a member of an interdisciplinary team. • Maintains knowledge of pertinent regulatory and accrediting requirements. • Maintains HIPAA standards and compliance with all state and federal regulations. • Ensures confidentiality of protected health information. • Performs special projects as assigned.