This role reviews clinical requests and utilization cases for medical necessity, appropriateness of care, and alignment with plan criteria. The clinician works across inpatient, outpatient, and other service requests, using clinical judgment to support timely review decisions and care coordination.
Key Responsibilities
- Conduct utilization review of medical services and treatment requests.
- Evaluate medical necessity and appropriateness of care against established criteria.
- Review inpatient and outpatient cases, including authorization-related requests.
- Coordinate with providers, members, and internal teams as needed to clarify clinical information.
- Document review findings and decisions in applicable systems.
- Support timely case processing and escalation when additional clinical review is needed.
Required
- Registered Nurse (RN) licensure.
- Clinical experience in utilization review, case review, or a related nursing setting.
- Ability to assess medical records and apply clinical criteria to care decisions.
Preferred
- Prior experience in managed care or health plan utilization management.
- Experience with authorization or medical necessity review processes.