Utilization Management RN

The Utilization Review III role evaluates member clinical information to determine coverage eligibility in alignment with medical policies, guidelines, and benefit requirements. The position uses advanced nursing judgment to review complex cases, document determinations, and ensure decisions support high-quality, appropriate care.

It contributes to utilization management outcomes by identifying clinical needs, applying established criteria, and maintaining accurate, timely documentation. This role also serves as a resource to colleagues and supports consistent, compliant review practices across the team. Performs other duties as assigned.