Utilization Review Case Manager

The Utilization Review Case Manager assesses medical necessity, appropriateness, and efficiency of patient care services using evidence‑based criteria such as InterQual, MCG, and the CMS Two‑Midnight Rule. The role conducts initial, concurrent, and retrospective reviews, collaborates with physicians, care coordinators, and payers, and works to secure authorizations, reduce denials, and ensure regulatory compliance and optimal patient outcomes.