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The Utilization Management Nurse Lead uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting data, criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. Accountable, in partnership with the Chief Medical Officer (CMO), to analyze utilization management (UM) trends and drivers impacting member outcomes and financial impact. You will support quality efforts both at the market and enterprise level, so achieve quality targets in HEDIS, STARS, and NCQA accreditation. The Utilization Management Nurse Lead advises executives to develop functional strategies (often segment specific) on matters of significance. They exercise independent judgment and decision making on complex issues regarding job responsibilitie...