State Licensed Utilization Review Specialist

Job Summary

Working remotely in a full-time capacity, the State Licensed Utilization Review Specialist will manage the review, investigation, and resolution of member and provider appeals and grievances, ensuring compliance with regulatory requirements and promoting quality outcomes.

Key responsibilities

• Conduct clinical reviews of member and provider appeals, assessing medical necessity and appropriateness of care
• Investigate grievances by analyzing medical records and documentation to determine root causes and resolutions
• Collaborate with Medical Directors and oversee Clinician-to-Clinician (C2C) challenges to ensure timely and compliant processing

Required qualifications

• Active, unrestricted clinical license (RN or LPN required)
• Minimum of 2-3 years of clinical experience in hospital, utilization management, or case management
• Prior experience in Appeals & Grievances or Managed Care is strongly preferred
• Familiarity with regulatory turnaround requirements and STARs metrics is preferred
• Strong knowledge of medical terminology and healthcare delivery systems