Utilization Management Nurse Consultant - Must reside in Florida
Core
Review clinical documentation and apply medical necessity criteria to make coverage determinations and manage healthcare services for members.
Role type
Utilization Management Nurse Consultant
Builds
Coverage determinations and care coordination for health plan members
Domain
Health insurance / Utilization Management
Deliverable
dashboards & analysis
Required skills
Clinical assessment, Medical necessity criteria application, Documentation review, Critical thinking, Care coordination, Triage
Preferred skills
Utilization Management experience, Managed Care experience, Discharge planning experience
Technologies
None stated
Responsibilities
Review clinical documentation and apply medical necessity criteria to make coverage determinations. Coordinate and communicate utilization and benefit management activities across the continuum of care. Collaborate with providers and internal stakeholders to facilitate treatment plans and care transitions. Support urgent and emergent member needs including triage and crisis intervention. Serve as a clinical resource regarding utilization management processes. Promote quality improvement initiatives to enhance healthcare outcomes.
Seniority
Mid-level, hands-on IC