Utilization Management Nurse Consultant

About This Role

This Utilization Management Nurse Consultant assesses and monitors patient health, administers medications and treatments, performs medical procedures, and collaborates with healthcare professionals to develop and implement patient care plans. The role drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources for members.

Responsibilities

• Assess and monitor patient health, administer medications and treatments, perform medical procedures
• Collaborate with physicians and other healthcare professionals to develop and implement patient care plans
• Educate patients and their families about healthcare management and assist in maintaining a safe and supportive healthcare environment
• Drive effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members
• Conduct routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate medical necessity and appropriateness of requested healthcare services
• Collaborate with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources
• Apply clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies
• Review and analyze medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization
• Consult with and provide expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function
• Communicate regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes

Requirements

• Working knowledge of problem solving and decision making skills
• Working knowledge of medical terminology
• Working knowledge of digital literacy skills
• Ability to deal tactfully with customers and community
• Ability to handle sensitive information ethically and responsibly
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients
• 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 (team is not accepting applicants whose only acute care experience is in behavioral health)

Qualifications

• Associate Degree In Nursing Is Minimum Required, BSN Preferred; Bachelor's degree preferred/specialized training/relevant professional qualification.
• 2+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience

Nice to Have

• Licensed Clinical Social Worker (LCSW)
• 1+ years’ experience Utilization Review experience
• 1+ years’ experience Managed Care
• Strong telephonic communication skills
• 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
• Experience with computers toggling between screens while using a keyboard and speaking to customers
• 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 use a computer station and sit for extended periods of time

Skills

* Required skills

Benefits