Utilization Management Nurse Consultant – EST/CST Zone

This is a fully remote position, open to applicants in Florida, +1 more state.

📋 Description

• Leverage 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 turnaround times.

• This role involves evaluating clinical documentation, collaborating with healthcare providers, and facilitating high-quality, cost-effective care.

• Assess services for medical necessity and proper benefit utilization.

• Aid in effective discharge planning.

• Work alongside providers and facilities to assist members with complex healthcare needs.

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

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

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

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

• Identify chances to enhance quality care delivery and efficient benefit utilization.

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

⛳️ Requirements

• Active, unrestricted RN license.

• A minimum of 2 years of acute hospital clinical experience, with a strong preference for medical-surgical, ICU, behavioral health, or other specialty areas.

• Strong clinical assessment and decision-making skills.

• Exceptional organizational abilities with a knack for managing multiple priorities.

• Capable of working independently and communicating effectively via phone.

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

• At least 1 year of Utilization Review experience is preferred.

• A minimum of 1 year of Managed Care experience is preferred.

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

• Strong telephonic communication skills are preferred.

• Proven ability to exercise sound judgment and collaborate with diverse teams is preferred.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources based on eligibility.