Position Summary

This is a fully remote Utilization Management Nurse Consultant opportunity.

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for customer service and claims processing areas.

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care

• Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs

• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• Typical office working environment with productivity and quality expectations.

• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

• Sedentary work involving periods of sitting, talking, listening.

• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

• Effective communication skills, both verbal and written

Required Qualifications

• 2+ years of clinical experience as an RN in acute or post-acute setting

• Must have active, current, and unrestricted RN licensure in state of residence

• 1 + years of experience using Microsoft Office products, including Teams, Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews

• Must be willing and able to work Monday through Friday, 8am to 5pm in time zone of residence

Preferred Qualifications

• Experience with CEC, MedCompass, HRP, IOP or claims/clinical review experience

• Experience working with adults and/or pediatrics outpatient therapy, i.e. occupational therapy, physical therapy, speech therapy, chiropractic, or acupuncture

• Experience working in a multidisciplinary team

Education

Associates degree required

BSN preferred