• Perform utilization management (UM) medical-necessity reviews and level-of-care determinations for requested services using the organization’s hierarchy of guidance (benefit language/plan documents, medical policies, nationally recognized evidence-based criteria such as MCG; NCCN as applicable) and applicable state/federal requirements.
• Apply criteria and policy consistently; when a request does not meet criteria, route timely to the Medical Director for secondary clinical review and potential adverse determination in accordance with UM policies and accreditation standards (e.g., NCQA/URAC, as applicable).
• Use critical thinking to analyze clinical documentation for completeness, identify key risk/acuity indicators, recognize inconsistencies or missing information, and initiate timely outreach/escalation per UM workflow.
• Apply strategic thinking within established guidelines by prioritizing workload based on urgency, regulatory/accreditation time frames, and potential member impact; communicate barriers early to support timely, compliant determinations.
• Assist with in-network and benefit-compliant redirection when clinically appropriate by confirming eligibility, benefits, authorization requirements, and network status.
• Support the appeals process by preparing clinical summaries and documentation; coordinating peer-to-peer/MD discussions when indicated; and ensuring timely routing/escalation per policy (including Independent Review Organization (IRO) processes when required).
• Document reviews, rationale, criteria/policy citations, communications, and outcomes accurately and contemporaneously in designated UM systems to support quality oversight, reporting, and audit readiness.
• Meet established productivity, quality, accuracy, and turnaround-time standards; participate in calibration/quality activities; and incorporate feedback into daily practice.
• Maintain HIPAA compliance and confidentiality using minimum-necessary standards; complete required training and annual competencies within established deadlines.
• Cross-train and provide cross-coverage as needed to support team operations and service-level commitments.

• Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable).
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred).
• Minimum 1-2 years of recent clinical experience (e.g., acute care, med-surg, ICU/ED, or other relevant setting).
• Prior utilization review/utilization management experience preferred.
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies with appropriate escalation to Medical Director for non-certifications.

• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• Ability to work independently within appropriate programs after training.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of MedCom.