Utilization Management (UM) Nurse Consultant - Work at Home in EST or CST Zone
Core
Coordinate, document, and communicate aspects of the utilization and benefit management process to ensure members receive safe, effective, and appropriate care.
Role type
Utilization Management (UM) Nurse Consultant
Builds
Coverage determinations and care coordination for health plan members
Domain
Health insurance / Utilization management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical assessment, decision-making, organizational skills, independent work, telephonic communication, documentation
Preferred skills
Utilization review experience, managed care experience, Microsoft Office proficiency, sound judgment
Technologies
Microsoft Office (Word, Excel, PowerPoint, Outlook)
Responsibilities
Review services for medical necessity and appropriate benefit use; facilitate efficient discharge planning; collaborate with providers and facilities; apply clinical criteria to make coverage determinations; communicate with external partners to coordinate care; identify opportunities for referrals; serve as a resource on UM processes.
Seniority
Mid-level, hands-on IC