RNUtilizationManagementReviewer

## **Ready to help us transform healthcare? Bring your true colors to blue. ** **The Role** The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health. This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care. **The Team** The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care. **Key Responsibilities:** * Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. * Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. * Pass annual InterQual Interrater Reliability Test. * Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care. * Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues. * Understand member insurance products and benefits, as well as regulatory and NCQA requirements. **Key Qualifications:** * Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team. * Ability to assess, analyze, draw conclusions, and construct effective solutions. * Proficient with multiple IT systems. * Demonstration of