Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Florida.

📋 Description

• Evaluate clinical documentation and implement medical necessity criteria, policies, and clinical guidelines to make coverage decisions and recommendations.

• Facilitate and communicate utilization and benefit management activities throughout the continuum of care.

• Work collaboratively with providers, healthcare teams, and internal stakeholders on treatment plans, discharge planning, and transitions of care.

• Utilize critical thinking and clinical judgment to advocate for evidence-based care and appropriate resource usage.

• Recognize members who could gain from care management programs and initiate referrals.

• Assist with urgent and emergent member needs, including triage and crisis intervention as necessary.

• Act as a clinical resource and consultant for both internal and external partners regarding utilization management processes and decisions.

• Foster quality improvement initiatives and pinpoint opportunities to enhance healthcare outcomes and benefit utilization.

⛳️ Requirements

• Active and unrestricted Registered Nurse (RN) license in the state of Florida.

• A minimum of 3 years of recent clinical nursing experience in an inpatient setting.

• Willingness and ability to obtain additional state nursing licenses as required (company-sponsored).

• Must be a permanent resident of Florida.

• Strong skills in clinical assessment, documentation, communication, and critical thinking.

• An Associate Degree in Nursing (ADN) is mandatory.

• Prior experience in Utilization Management (UM) is preferred.

• Experience in Managed Care is preferred.

• Background in discharge planning and care coordination is preferred.

• Familiarity with medical necessity guidelines and utilization review criteria is preferred.

• Work schedules may include evenings, weekends, and holidays.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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