Job Description

Your Role

The Utilization Management team independently manages complex utilization and retrospective clinical reviews across multiple lines of business, assessing medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements while supporting clinical consistency, process improvement, quality, timeliness, and appropriate escalation of high-risk cases.

Responsibilities

Your Work
In this role, you will:

• Independently manages complex prospective, concurrent, and retrospective utilization reviews across multiple lines of business
• Conducts retrospective clinical reviews of claims for medical necessity, coding accuracy, medical policy, and contract compliance
• Serves as a clinical subject matter resource to peers by providing guidance on criteria application, documentation, and processes
• Evaluates treatment plans, lengths of stay, and discharge planning to ensure quality, cost effective utilization of services
• Identifies overpayment, third party liability, and coordination of benefits opportunities and initiates appropriate follow up
• Supports process improvement efforts to enhance clinical consistency, efficiency, and regulatory compliance
• Escalates complex or high risk cases to leadership or Medical Directors with clear clinical rationale
• Works with minimal supervision while maintaining accountability for quality, accuracy, and timeliness
• Ability to work evenings and weekends as part of rotating on-call schedule

Qualifications

Your Knowledge and Experience

• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting
• Maintain active, unrestricted RN License in assigned states or the ability to obtain required state (in addition to primary state license) RN license within 90 days of hire

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.