Senior Utilization Review Nurse I

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for applying advanced clinical and regulatory knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the level of care and duration of treatment required for complex and/or escalated reviews, and providing guidance to team members and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating and/or adjudicating referrals to appropriate services based on medical necessity.

Essential Responsibilities:


+ Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to manage...