Utilization Management Nurse Consultant
Core
Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members using clinical criteria and guidelines.
Role type
Utilization Management Nurse Consultant
Builds
Coverage determinations and recommendations along the continuum of care
Domain
Health insurance / Utilization management
Required skills
Clinical judgment, coverage determination, care coordination, provider communication, policy application, productivity management
Preferred skills
Utilization Management experience, acute or post-acute clinical experience
Technologies
Multiple clinical systems, computer systems
Responsibilities
Gather clinical information and apply criteria to render coverage determinations; Communicate with providers to facilitate care and identify referral opportunities; Identify opportunities to promote quality and effectiveness of healthcare services; Consult with internal and external constituents on utilization management; Meet set productivity and quality expectations
Seniority
Mid-level, hands-on IC