Utilization Management Nurse Consultant – Medical Review

Job Description: • 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 • Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements 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 • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility Apply tot his job