Utilization Management Nurse Consultant – Cst

Utilization Management Nurse Consultant – Cst

Requirements

• Registered Nurse in state of residence.
• 3+ years of Nursing experience.

Responsibilities

• 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.

Preferred Qualifications

• Prior authorization utilization management/review experience preferred Outpatient Clinical experience.
• Knowledge of Medicare/Medicaid Managed care experience.