Utilization Management Nurse Consultant, EST Zone

This is a fully remote position, open to applicants in Florida, +4 more states.

📋 Description

• Leverage your clinical expertise to coordinate, document, and communicate all elements of the utilization and benefit management process.

• Ensure that members receive the most suitable level of care while adhering to state and federal requirements and turnaround times.

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

• Assess services for medical necessity and appropriate benefit utilization.

• Facilitate efficient discharge planning.

• Partner with providers and facilities to assist members with complex needs.

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

• Communicate with providers and external partners to coordinate care and treatment plans.

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

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

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

⛳️ Requirements

• Active and unrestricted RN license.

• Minimum of 2 years of acute hospital clinical experience (strong preference for medical-surgical, ICU, behavioral health, or other specialty areas).

• Strong clinical assessment and decision-making skills.

• Excellent organizational abilities with the capability to manage multiple priorities.

• Capacity to work independently and communicate effectively via phone.

• Proficiency in computer-based work, managing multiple screens, and documenting while on calls.

• At least 1 year of Utilization Review experience (preferred).

• At least 1 year of Managed Care experience (preferred).

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

• Strong telephonic communication skills (preferred).

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Comprehensive benefits package.