Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program
Reviews services to assure medical necessity
Applies clinical expertise to assure appropriate benefit utilization
Facilitates safe and efficient discharge planning
Works closely with facilities and providers to meet the complex needs of the member
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.

RN with active and unrestricted state licensure in their state of residence
2+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience
1+ years’ experience Utilization Review experience (preferred)
1+ years’ experience Managed Care (preferred)
Strong telephonic communication skills
1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills
Ability to manage multiple priorities, effective organizational and time management skills required
Ability to use a computer station and sit for extended periods of time

Utilization Management Nurse Consultant

Key skills