Nurse Reviewer, Utilization Management

The Nurse Reviewer, Utilization Management performs prospective, concurrent, and retrospective medical necessity reviews to ensure members receive appropriate, high-quality care within a TRICARE Prime/USFHP framework. This role applies nationally recognized medical necessity criteria to authorization requests, coordinates with providers, and escalates cases requiring physician-level judgment. The position supports compliant, timely utilization decisions while identifying members who may benefit from case management or behavioral health support.