Utilization Review Nurse- Remote

Assess medical necessity, quality of care, and appropriateness of health services for plan members by conducting pre-service, concurrent, and retrospective utilization reviews. Identify placement settings offering the lowest restriction and greatest autonomy based on medical necessity. Conduct outreach to specialty physicians, ancillary providers, and institutions to gather clinical data, then apply review criteria and guidelines to determine medical necessity. Certify cases meeting clinical standards and consult with physicians when criteria are not met. Refer cases to internal case management or medical consultation as indicated and ensure risk management issues are reported to the Director of Medical Management in a timely manner. Adhere to accreditation, contractual, and regulatory timeframes for all review processes.