Position Summary

Utilization management is a 24/7 operation.  Work schedules may include weekends and holidays and evening rotations.

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. 

• 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.

• Typical office working environment with productivity and quality expectations.

• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

• Sedentary work involving periods of sitting, talking, listening.

• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

• Effective communication skills, both verbal and written

Required Qualifications

• 3+ years of experience as a Registered Nurse

• Must have active current and unrestricted RN licensure in state of residence

• 1+ years of clinical experience in acute or post acute setting

• 1+ years of Microsoft Office Suites experience required

• Utilization management is a 24/7 operation.  Work schedules will include a minimum of 6 weekend rotations per year, as well as holidays and evening rotations.

• Candidates must be able to work Mon-Fri 8:30am-5pm or 10:30 am - 7pm PST.

Preferred Qualifications

• 3+ years of clinical experience required

• Managed Care experience preferred

Education

Associates Degree or equivalent nursing diploma required

BSN preferred