Utilization Management Nurse Consultant

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

📋 Description

• Utilize your clinical expertise to manage, document, and communicate all facets of the utilization and benefit management process.

• Ensure that members receive the most suitable level of care while adhering to state and federal regulations and timelines.

• Analyze clinical documentation, collaborate with healthcare providers, and promote high-quality, cost-effective care.

• Assess services for medical necessity and appropriate benefit utilization, facilitate efficient discharge planning, and work with providers and facilities to assist members with complex needs.

• Leverage clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.

• Gather and assess clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage decisions.

• Engage with providers and external partners to coordinate care and treatment strategies.

• Identify potential referrals to additional programs, services, or care solutions.

• Spot opportunities to enhance quality care delivery and effective benefit utilization.

• Act as a resource for both internal and external stakeholders concerning UM processes and clinical considerations.

⛳️ Requirements

• Current, unrestricted RN license.

• Over 2 years of acute hospital clinical experience (preferably in medical-surgical, ICU, behavioral health, or other specialty areas).

• Strong capabilities in clinical assessment and decision-making.

• Exceptional organizational skills with the capacity to manage multiple priorities.

• Ability to work independently and communicate effectively over the phone.

• Comfortable with computer-based tasks, multitasking across various screens, and documenting while on calls.

• More than 1 year of experience in Utilization Review (preferred).

• More than 1 year of experience in Managed Care (preferred).

• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) (preferred).

• Strong telephonic communication abilities (preferred).

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources based on eligibility.