Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Alabama, +46 more states.

📋 Description

• Oversee, document, and communicate all facets of the utilization and benefit management program.

• Promote effective utilization management by ensuring the appropriate and cost-efficient allocation of healthcare resources.

• Perform utilization reviews and assessments utilizing evidence-based criteria and clinical expertise.

• Assess the medical necessity and suitability of requested healthcare services.

• Collaborate with healthcare providers, multidisciplinary teams, and payers to create and implement care plans.

• Examine and analyze medical records, treatment plans, and documentation for adherence to guidelines, policies, and regulations.

• Offer recommendations for care coordination and resource optimization.

• Engage with internal and external stakeholders to facilitate care coordination and address inquiries related to utilization management.

• Provide coaching and support to nursing staff and healthcare professionals.

• Contribute to the development of utilization management strategies, policies, and procedures.

• Facilitate safe and efficient discharge planning with facilities and providers.

• Collect clinical information and implement clinical criteria, policies, procedures, and judgment to make coverage determinations or recommendations.

• Identify referral opportunities and areas for enhancing healthcare quality and benefit utilization.

• Work Monday through Friday during standard hours in the residence time zone, with occasional varying shifts and a rotational late shift.

⛳️ Requirements

• Registered Nurse (RN) with active and unrestricted state licensure in their state of residence.

• Associate Degree in Nursing is the minimum educational requirement.

• A minimum of 2 years of acute hospital clinical experience as an RN.

• Preference for experience in medical-surgical and ICU settings.

• Applicants whose only acute care experience is in behavioral health will not be considered.

• Proficient problem-solving and decision-making skills.

• Familiarity with medical terminology.

• Proficient digital literacy skills.

• Ability to interact tactfully with customers and the community.

• Ability to manage sensitive information ethically and responsibly.

• Ability to evaluate the relative costs and benefits of potential actions.

• Ability to function in a clinical environment with diverse cultural dynamics.

• Preferred: At least 1 year of experience in Utilization Review.

• Preferred: At least 1 year of experience in Managed Care.

• Strong telephonic communication skills.

• Preferred: At least 1 year of experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook).

• Experience using a computer while navigating between screens, keyboarding, and engaging with customers.

• Ability to exercise independent and sound judgment.

• Strong decision-making and interpersonal skills.

• Ability to manage multiple priorities with effective organizational and time management skills.

• Capability to use a computer station and sit for extended periods.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.