The Utilization Appeals Review Nurse is responsible for the clinical review and resolution of member and provider appeals and claims disputes by applying medical policies and regulatory standards. This role involves coordinating clinical resolution, ensuring compliance with various contractual and regulatory standards, and participating in quality improvement initiatives.

The role involves performing concurrent reviews to determine a member's overall health, evaluate the necessity and setting of care being delivered, and contribute to discharge planning according to established policies. Responsibilities also include collecting and documenting review findings, working with healthcare providers to approve medical determinations, and assisting with provider education on utilization processes.

The scout will be responsible for attending high school and club games, watching film, and publishing player-driven written and social media content on the Company website. Duties also include promoting players for collegiate recruitment and networking with coaches to expand the Company brand.

The Clinical Care Reviewer II is responsible for processing medical necessity reviews for behavioral health services, assisting with discharge planning, and coordinating care for members. Essential functions include completing prospective, concurrent, and retrospective reviews and engaging collaborative care partners to facilitate transitions to appropriate levels of care.