This role focuses on care review and utilization management for members with acute and chronic needs, using clinical judgment to assess medical necessity and appropriate levels of care. The clinician reviews cases, coordinates with providers and internal teams, and supports timely decisions across the care continuum. Work is remote for candidates residing in PST or MST.
Key Responsibilities
- Conduct care review and utilization management activities for member cases
- Assess medical necessity, appropriateness of services, and level of care using clinical criteria
- Coordinate with physicians, facilities, and internal care teams to support decision-making
- Review clinical documentation and complete timely case determinations
- Participate in care coordination activities that support transitions across settings
- Use clinical judgment to identify needs for additional review, escalation, or follow-up
Required
- Active RN licensure
- Relevant nursing experience in care review, utilization management, case management, or a similar setting
- Ability to work remotely while residing in PST or MST