Utilization Management Nurse Consultant
Core
Conduct utilization management and prior authorization reviews to ensure members receive medically appropriate, cost-effective care based on established clinical guidelines and benefit plans.
Role type
Utilization Management Nurse Consultant (Clinical Precertification RN)
Builds
Coverage determinations and care coordination for Medicare members
Domain
Healthcare / Managed Care / Medicare
Required skills
Clinical assessment, analytical skills, decision-making, Microsoft Office proficiency, secure system navigation
Preferred skills
Medicare guidelines knowledge, Prior Authorization experience, Managed care experience, MedCompass platform experience, BSN degree
Responsibilities
Review cases for medical necessity, collaborate with providers and interdisciplinary teams, make coverage determinations, adhere to clinical guidelines
Seniority
Mid-level, hands-on IC