• Identifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims • Acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits • Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies • Identifies, documents, and escalates system and process problems • Through analysis, determines root cause and recommends possible solutions • Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria • Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries • Issues denials according to department protocols • Documents outcome of reviews • Maintains confidentiality of all PHI in compliance with state and federal laws • Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner • Identifies situations in which claims filing/coding guidelines are not being followed by providers • Communicates with members and providers to obtain additional information • Informs members, providers, and internal customers of claims status and determinations • Performs post adjudication review of claims related to coding, billing and reimbursement