Conducts reviews of medical records and treatment plans to evaluate and consult on necessity, appropriateness, and efficiency of health care services and provides expert guidance to team members. Drives the communication efforts with physicians, managers, staff, members and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care. Identifies utilization trends, leads efforts for improvement initiatives, and facilitates the development and implementation of corrective action plans to address deficiencies, evaluate effectiveness, and track improvements in utilization review workflow/processes and ensure compliant and cost-effective care. Facilitates education and compliance initiatives by remaining up-to-date on the relevant regulations and guidelines and driving the development and delivery of education and training programs for staff and physicians to promote best practices in utilization management at the local and regional level.