Utilization Management Nurse Consultant

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Position Summary

Utilization Management is a 24/7 operation and work schedules may include weekends, holidays, and evening hours.

This Utilization Management (UM) Nurse Consultant role is 100% remote, and the candidate can live in any state, however; preference will be given to those in Pacific Time Zone or willing to work Pacific Time Zone hours.

 As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.

The UM Nurse Consultant job duties include (not all encompassing):

Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

• 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

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