A bit about this role: Under the guidance of the Manager, Clinical Services and Escalations the Clinical Nurse Specialist will function in a very cross functional, diverse capacity working with multiple areas to include as example: UM Operations, Claims, Appeals, Grievances, Quality, Provider Disputes, Payment Integrity, Policy Improvement, Compliance, and other clinical and operational stakeholders. Analyze trends across pended claims, appeals, clinical escalations, provider disputes, and utilization management workflows, partnering with cross-functional teams to identify systemic issues and recommend process improvements.