Utilization Management Nurse Consultant (UM) - Work at Home CST Zone
Core
Coordinate, document, and communicate aspects of the utilization and benefit management process to ensure members receive safe, effective, and appropriate care.
Role type
Utilization Management Nurse Consultant
Builds
Coverage determinations and care coordination for health plan members
Domain
Health insurance / Utilization Management
Required skills
Clinical assessment, decision-making, documentation, telephonic communication, benefit utilization review, discharge planning, policy application
Preferred skills
Utilization Review experience, Managed Care experience, Microsoft Office proficiency
Responsibilities
Review services for medical necessity and appropriate benefit use; Apply clinical criteria to make coverage determinations; Collaborate with providers to coordinate care and treatment plans; Identify opportunities for referrals to additional programs or services; Serve as a resource regarding UM processes and clinical considerations
Seniority
Mid-level, hands-on IC