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 recommendations
Domain
Healthcare / Utilization Management
Required skills
Clinical assessment, documentation review, critical thinking, care coordination, triage, crisis intervention
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; Collaborate with providers to facilitate treatment plans and care transitions; Support urgent and emergent member needs including triage and crisis intervention; Serve as a clinical resource for utilization management processes; Promote quality improvement initiatives.
Seniority
Mid-level, hands-on IC