CommunityCare

The Clinical Pharmacist is responsible for managing medication utilization, reviewing prior authorization requests, and ensuring evidence-based clinical criteria are met. They also collaborate with multidisciplinary teams to optimize member outcomes and support clinical policy development.

The Registered Nurse is responsible for performing clinical utilization reviews to determine medical necessity and appropriateness of services. They collaborate with physicians and providers to facilitate care coordination and ensure accurate documentation of all review determinations.

The Registered Nurse is responsible for performing clinical utilization reviews to determine the medical necessity and appropriateness of services. They collaborate with providers and the care management team to facilitate care coordination and ensure accurate documentation of all review determinations.

The role involves performing clinical reviews of utilization requests and determining medical necessity for various patient populations. The nurse will collaborate with physicians and providers to facilitate care and ensure accurate documentation of all review determinations.

Leads governance, audit readiness, and performance improvement across Physical, Behavioral, and Pharmacy Utilization Management and Appeals and Grievances. Oversees internal and delegated entity auditing, corrective action plans, and the alignment of policies and procedures to meet regulatory requirements.