Utilization Management Nurse Consultant (Work From Home)
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
Utilization and benefit management decisions for health plan members
Domain
Health Insurance / Utilization Management
Required skills
Clinical assessment, decision-making, evidence-based guideline application, Microsoft Office proficiency
Preferred skills
Utilization Management experience, Prior Authorization experience, Managed care background, Ambulatory surgery background
Responsibilities
Review clinical cases and make coverage determinations, Collaborate with providers and care teams to complete precertification requests, Apply clinical judgment to support utilization decisions, Identify opportunities to improve care quality and member outcomes, Serve as a clinical resource across internal and external stakeholders