This role reviews medical service requests and appeals for medical necessity, using clinical judgment to evaluate cases against coverage criteria. The work is primarily utilization management focused and is suited to an RN with experience in UM and appeals processes.
Key Responsibilities
- Conduct clinical reviews of medical requests for appropriateness and medical necessity.
- Review and process appeals using established coverage criteria and documentation.
- Coordinate with internal teams to support timely review and decision-making.
- Use clinical judgment to evaluate cases within utilization management workflows.
- Document review findings and determinations in applicable systems.
Required
- Active Registered Nurse (RN) license.
- Experience in utilization management and appeals review.