Clinical Quality & Utilization Review Specialist

Under the supervision of the Director of Utilization Management, the Clinical Quality and Utilization Review Specialist performs a dual role encompassing utilization management and peer review. This position is responsible for assessing the medical appropriateness, efficiency, and quality of healthcare services across inpatient and outpatient settings, including authorization review and utilization oversight. In parallel, the RN coordinates peer review activities including screening, reviewing, and preparing cases and facilitating Root Cause Analyses (RCAs) to evaluate clinical performance and identify opportunities for improvement. The Clinical Quality and Utilization Review Specialist partners closely with physicians, advanced practice providers (APPs), and interdisciplinary teams to...