Leading the appeals process, the full-time SD Licensed RN Lead Utilization Specialist will provide case oversight, workflow coordination, and quality assurance while collaborating across departments in a fully remote setting. Key responsibilities Serve as the subject matter expert for appeals and denials, addressing complex questions and issues Conduct reviews of clinical-based denials, utilizing clinical criteria and knowledge of payor regulations Lead team meetings and develop process improvement initiatives to enhance workflow and compliance Required qualifications Bachelor's degree in nursing preferred; graduation from a nationally accredited nursing program required Three years of related experience required Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing Certified Professional in Healthcare Quality preferred Must obtain and maintain required department-specific competencies and certifications