Responsible for collaboration with healthcare providers and members to promote quality member outcome, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Review documentation and interpret data obtained from clinical records such as patient laboratory results, diagnostic tests, office visit notes and medical history.