Utilization Management Nurse Consultant

Utilization Management Nurse Consultant

Requirements

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed.
• Minimum 5 years of relevant nursing experience.
• Minimum 3 years of clinical experience in acute care, long term acute care (LTAC) or skilled nursing facility.
• At least 1 year of Utilization Management experience within an Inpatient/Outpatient setting, concurrent review or prior authorization.
• Strong decision-making skills and clinical judgment in independent scenarios.
• Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms.
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

Responsibilities

• Apply critical thinking and evidence-based clinical criteria to evaluate inpatient and outpatient services requiring precertification.
• Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information.
• Use established guidelines to authorize services or escalate to Medical Directors as needed.
• Navigate multiple computer systems efficiently while maintaining accurate documentation.
• Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills.
• Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer.
• Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM departmental teams as needed, ensuring continuity of care and operational support.
• Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

Preferred Qualifications

• 1+ year of experience in a managed care organization (MCO).
• Experience in a high-volume clinical call center or prior remote work environment.