• Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines (MCG, InterQual) and CMS criteria • Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment • Engage in peer-to-peer discussions with attending physicians to clarify clinical documentation and support the appropriate level of care • Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays • Ensure all decisions are documented in strict accordance with NCQA, CMS, and organizational standards • Contribute expertise to initiatives focused on readmission reduction and transitions of care