State Licensed Utilization Review Specialist

Job Summary

To support quality outcomes and member satisfaction, the full-time remote State Licensed Utilization Review Specialist will conduct clinical reviews of member and provider appeals, evaluate medical necessity, and oversee clinician-to-clinician challenge activities.

Key Responsibilities

• Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases
• Investigate grievances by reviewing medical records and claims to determine root cause and resolution
• Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed

Required Qualifications

• Active, unrestricted clinical license (RN or LPN license required)
• 5+ years of clinical experience
• Prior experience in Appeals & Grievances, Utilization Management, or Managed Care strongly preferred
• Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred
• Strong knowledge of medical terminology and healthcare delivery systems