Utilization Management Nurse Consultant

Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. You will apply clinical experience and skills to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members. Your work will involve gathering clinical information, applying guidelines, policies, and clinical judgment to render coverage determination and recommendations along the continuum of care, communicating with providers and other parties to facilitate care, identifying referral opportunities, promoting quality effectiveness of health services and benefit utilization, and consulting with internal and external constituents in the coordination and administration of utilization/benefit management. Responsibilities Utilize 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. Gather clinical information and apply the appropriate clinical criteria, guidelines, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicate with providers and other parties to facilitate care/treatment. Identify members for referral opportunities to integrate with other products, services and/or programs. Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization. Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Work in a typical office environment with productivity and quality expectations. Interpret hand‑written and computer‑generated documents; monitor PC screen. Multitask, prioritize, and adapt to fast‑paced changing environment. Use computer skills (navigating multiple systems and keyboarding). Effectively communicate verbally and in writing. Qualifications 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. Active, current and unrestricted RN licensure in state of residence. 2+ years of clinical experience in medical‑surgical or specialty area. Managed Care experience preferred, especially Utilization Management. Preference for candidates residing in Central Time zones. Associate’s Degree required; BSN preferred. Ability to work a 24/7 schedule that includes weekends, holidays, and evenings. Work Hours Anticipated weekly hours: 40. Time Type Full time. Pay Range The typical pay range for this role is $26.01 – $56.14 per hour. Actual base salary will depend on experience, education, geography and other factors. Benefits This full‑time position is eligible for a comprehensive benefits package that may include medical, dental, and vision coverage; paid time off; retirement savings options; wellness programs; and other resources based on eligibility. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr