Utilization Management Nurse Consultant

Utilization Management Nurse Consultant

Requirements

• Active and unrestricted RN licensure in the state of residence
• Willingness to obtain additional licensure upon hire – paid for by the company
• 3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care

Responsibilities

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support).
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs and facilitates referral.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Preferred Qualifications

• NICU experience highly preferred
• Managed care/utilization review experience
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Proficiency with personal computers, keyboard, and multi-systems navigation, and MS Office Suite applications