Utilization Management Nurse Consultant – Medical Review

Role Overview

• Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases
• Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client
• Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines
• Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed
• Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback
• Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs
• Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction
• Must be able to work independently without personal distractions to meet quality and metric expectations

Requirements

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges
• Ability to obtain licensure in non-compact states as needed
• Minimum 3 years of clinical experience
• 5 years demonstrated to make thorough independent decisions using clinical judgement
• 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems
• 1+ Year of Utilization Review Management and/or Medical Management experience
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs
• Confidential counseling and financial coaching
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access