Utilization Review III

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.