Utilization Review III

Medica•,

16h•$70,200 - $120,400•Remote

About The Position

The Utilization Review III position is responsible for the review, investigation, and resolution of member and provider appeals and grievances requiring clinical expertise. This role ensures compliance with regulatory requirements, accreditation standards, and organizational policies while promoting quality outcomes, member satisfaction, and STARs performance. The specialist works collaboratively with medical directors, clinical staff, and operational teams to support timely and accurate determinations and oversee clinician-to-clinician (C2C) challenge activities.

Requirements

Active, unrestricted clinical license (RN or LPN license required).
Minimum of 2–3 years of clinical experience (e.g., hospital, utilization management, case management).
Strong knowledge of medical terminology, clinical guidelines, and healthcare delivery systems.
Understanding of regulatory requirements (CMS, Medicare/Medicaid, commercial guidelines, NCQA standards).
Excellent critical thinking and clinical decision-making skills.
Strong written and verbal communication skills, including the ability to translate clinical information into member-friendly language.
Exceptional attention to detail and organizational skills.
Ability to manage multiple priorities and meet strict deadlines.
Proficiency in case management systems and Microsoft Office applications.
Must be legally authorized to work in the United States at the time of application.

Nice To Haves

Prior experience in Appeals & Grievances, Utilization Management, or Managed Care strongly preferred.
Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred.
Familiarity with STARs measures and how clinical decisions impact quality performance outcomes.

Responsibilities

Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases.
Evaluate medical necessity, appropriateness of care, and benefit coverage using clinical guidelines and evidence-based criteria.
Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution.
Prepare clear, concise, and compliant determination letters that meet regulatory and accreditation standards (e.g., CMS, NCQA).
Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed.
Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and ensuring timely completion in accordance with regulatory requirements.
Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance improvement.
Partner with quality and operations teams to address trends that may negatively impact STARs ratings and member experience.
Ensure all appeals and C2C activities are processed within required turnaround times.
Identify trends, quality concerns, and potential process improvement opportunities through case analysis.
Maintain accurate and complete documentation in case management systems.
Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways.
Participate in audits, regulatory reporting, and quality improvement initiatives as required.