Utilization Management Nurse Consultant

Clinical Precertification: Commercial

Must be willing and able to work Monday through Friday, 9am to 6pm EST with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours.

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.

• Communicates with providers and other parties to facilitate care/treatment

• Identifies members for referral opportunities to integrate with other products, services and/or programs

• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Required Qualifications

• 3+ years of experience as a Registered Nurse

• Must have active current and unrestricted RN licensure in state of residence

• 1+ years of Med/Surg experience

• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)

• Must be willing and able to work Monday through Friday, 9:00am to 6:00pm eastern time with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

Preferred Qualifications

• Prior Authorization or Utilization Management experience

• Managed care experience

• Experience using MedCompass

• Ambulatory surgery experience

Education

• Associates degree required

• Bachelor's in Science and Nursing preferred