• RN Clinician responsible for utilization management services within the scope of licensure. • Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. • Reviews provider requests for services requiring authorization. • Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. • May manage appeals for services denied. • Responsible for written and/or verbal notification to members and providers. • Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition. • Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.