Utilization Management Registered Nurse

What You’ll Be Doing:

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately.
• Communicate decisions to required parties within defined timeframes.

Clinical Consultation & Collaboration:

• Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation.
• Communicate routinely with ordering providers and provider organizations.
• Communicate with members or their representatives.

Care Coordination & Member Support:

• Identify and refer eligible members to disease management programs.
• Manage and document on‑call phone communications with members and providers.

Compliance, Quality & Documentation:

• Maintain confidentiality of all member information and case records.
• Participate in quality management initiatives and support related documentation.
• Assist with the design and maintenance of clinical reports.