Utilization Management Nurse Consultant
Core
Review clinical information to support coverage determinations and care decisions, applying nursing judgment across the continuum of care.
Role type
Utilization Management Nurse Consultant
Builds
Coverage determinations and care coordination plans 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, application of clinical guidelines, care coordination, multitasking, technology navigation
Preferred skills
Managed care experience, Utilization Management experience, Med-Surg or specialty clinical experience
Technologies
Microsoft Office 365, EHR portals, VPN, Teams, Outlook, Excel
Responsibilities
Review and assess clinical information to support coverage determinations; Apply clinical guidelines and nursing judgment; Collaborate with providers to coordinate care; Identify opportunities for improved healthcare quality and member outcomes; Refer members to appropriate programs and services
Seniority
Mid-level, hands-on IC