Utilization Management Nurse Consultant
Core
Utilizes clinical experience to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members, rendering coverage determinations based on clinical criteria and guidelines.
Role type
Utilization Management Nurse Consultant
Builds
Coverage determinations and care coordination recommendations
Domain
Healthcare administration / Utilization Management
Deliverable
client delivery
Required skills
Med Surg nursing experience, RN licensure, clinical judgment, policy application, provider communication, IT platform navigation
Preferred skills
Medicare/Medicaid knowledge, managed care experience, Utilization Management experience
Responsibilities
Assess and evaluate healthcare service options, gather clinical information to render coverage determinations, communicate with providers to facilitate care, identify referral opportunities, consult on utilization management functions
Seniority
Mid-level, hands-on IC