Utilization Review III

Utilization Review III conducts clinical reviews of member and provider appeals across pre-service, concurrent, and post-service cases, evaluating medical necessity, appropriateness of care, and benefit coverage using evidence-based criteria. The role investigates grievances by reviewing medical records and related documentation to determine root cause and resolution, and prepares clear, compliant determination letters meeting CMS/NCQA standards. It collaborates with Medical Directors for physician-review cases, oversees clinician-to-clinician (C2C) challenges and ensures timely completion per regulatory requirements, monitors STARs measures, identifies opportunities for performance improvement, and maintains accurate case management documentation. The position supports non-clinical staff with appeals processes and participates in audits, regulatory reporting, and quality improvement initiatives. Requires active clinical license (RN or LPN), 2–3 years of clinical experience, and familiarity with regulatory requirements and STARs; this is a remote role with eligibility limited to states where Medica is registered as an employer (AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI). Salary range listed from $70,200 to $120,400, with typical hiring range $70,200 to $105,315, plus comprehensive benefits; visa sponsorship is not offered.