Utilization Management Nurse Consultant
Core
Review clinical cases and make coverage determinations using evidence-based guidelines to ensure members receive the right care at the right time.
Role type
Utilization Management Nurse Consultant (Clinical Precertification)
Builds
Coverage determinations and care coordination decisions for Medicare members
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical assessment, decision-making, evidence-based guideline application, care coordination, stakeholder collaboration
Preferred skills
Utilization management, prior authorization, managed care, ambulatory surgery
Technologies
Microsoft Office (Outlook, Teams, Excel), MedCompass, EHR portals, VPN
Responsibilities
Review clinical cases and make coverage determinations, Collaborate with providers to coordinate treatment, Apply clinical judgment to support benefit management decisions, Identify opportunities to improve care quality, Serve as a clinical resource for stakeholders
Seniority
Mid-level, hands-on IC