Utilization Management Registered Nurse (RN)

Utilization Review & Clinical Determinations:

• Performing timely reviews of healthcare services using approved medical necessity criteria.
• Accurately documenting clinical findings and determinations per regulatory standards.
• Communicating determinations to providers and members within required timeframes.

Clinical Collaboration:

• Collaborating with Medical Director and Peer Reviewers on complex cases.
• Interfacing with ordering providers and integrating AI into daily workflow.

Care Coordination & Quality Support:

• Initiating referrals to disease management programs for continuity of care.
• Participating in quality management and performance improvement initiatives.

Compliance & Professional Standards:

• Maintaining confidentiality and ensuring compliance with federal and state regulations.
• Integrating URAC standards and medical group guidelines into daily activities.