The Medical Director will conduct medical necessity determinations for inpatient and post-acute care while ensuring compliance with CMS and NCQA standards. They will also lead peer-to-peer discussions and collaborate with care management teams to optimize clinical outcomes and utilization trends.
The Physician Advisor will conduct peer-to-peer clinical discussions with providers to determine medical necessity and appropriate level of care. They are responsible for documenting outcomes, ensuring regulatory compliance, and identifying clinical trends to support utilization management leadership.
