Determines the medical necessity of requests using clinical criteria. Performs physician-level case review of surgical utilization requests. Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service. Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options. Performs first level provider appeals for coverage decisions. Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management of conditions and surgical procedures. Participates in physician team meetings. Participates in groups that develop, revise and enhance clinical appropriateness guidelines. Minimum Requirements:Requires MD and/or DO, completion of training in General Surgery, Surgical Subspecialties, or specialties that perform interventional procedures. Requires board certification by either the American Board of Medical Specialties or the American Osteopathic Association Specialties. Requires a current, valid, active and unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s). Requires a minimum of 5 years of clinical experience. Preferred Qualifications:Experience with utilization management, especially with CMS guidelines preferred. Preferred board certifications include: Plastic surgery, Ophthalmology, Otolaryngology (ENT), Gastroenterology, and Interventional radiology. California license strongly preferred. Job Level:Director Equivalent. Workshift:1st Shift (United States of America)