Utilization Nurse Consultant

Role Overview

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Requirements

• 3+ years of experience as an RN
• Active and unrestricted RN licensure in state of residence
• Able to work in multiple IT platforms/systems
• 1+ years of experience with Microsoft Office Applications (Outlook, Teams, Excel)

Benefits

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility