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Utilization Management Nurse Consultant – EST/CST Zone

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Job Description:

  • Use clinical background to coordinate, document, and communicate all aspects of utilization and benefit management process.
  • Ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times.
  • Involves reviewing clinical documentation, collaborating with providers, and supporting high-quality, cost-effective care.
  • Reviewing services for medical necessity and appropriate benefit use.
  • Facilitating efficient discharge planning.
  • Collaborating with providers and facilities to support members with complex needs.
  • Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.
  • Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations.
  • Communicating with providers and external partners to coordinate care and treatment plans.
  • Identifying opportunities for referrals to additional programs, services, or care solutions.
  • Recognizing opportunities to promote quality care delivery and effective benefit utilization.
  • Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.

Requirements:

  • Active, unrestricted RN license
  • 2+ years of acute hospital clinical experience (strong preference for medical-surgical, ICU, behavioral health or other specialty area)
  • Strong clinical assessment and decision-making abilities
  • Excellent organizational skills with the ability to manage multiple priorities
  • Ability to work independently and communicate effectively via phone
  • Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls.
  • 1+ year of Utilization Review experience (preferred)
  • 1+ year of Managed Care experience (preferred)
  • Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) (preferred)
  • Strong telephonic communication skills (preferred)
  • Demonstrated ability to exercise sound judgment and collaborate with diverse teams (preferred)

Benefits:

  • medical, dental, and vision coverage
  • paid time off
  • retirement savings options
  • wellness programs
  • other resources, based on eligibility
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