Utilization Management Nurse Consultant - Work at Home EST / CST
About The Position
The Utilization Management Nurse Consultant uses clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options that facilitate appropriate healthcare services and benefits for members. The role gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations across the continuum of care. It also communicates with providers and other parties to facilitate care and treatment, identifies members who may benefit from other products, services, or programs, and looks for opportunities to improve the quality and effectiveness of healthcare services and benefit utilization. The consultant provides expertise to internal and external constituents in coordinating and administering utilization and benefit management. This is a work-from-home role for candidates residing in the Eastern or Central time zones. Utilization Management operates 24/7, and schedules include weekends, holidays, and evening hours. The position involves a typical office environment with productivity and quality expectations, extended periods of sitting, telephone conversations, computer use, and multitasking in a fast-paced, changing environment. Work-from-home requirements include a quiet, secure, private, designated workspace compliant with company and HIPAA guidelines, and a direct wired internet connection meeting the stated speed requirements. The company provides computer equipment, while the employee supplies workspace furniture.
Requirements
- At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
- Active, current, unrestricted RN license in the state of residence.
- Must reside in the Eastern or Central time zone and work within the state and city where currently living.
- Associate degree required.
- Ability to work schedules that may include weekends, holidays, and evening hours.
- Ability to use multiple monitors and applications simultaneously and communicate through email, calendar invitations, Teams messaging, and virtual meetings.
- Ability to use Microsoft Office 365 applications or similar tools.
- Ability to access secure systems, follow basic computer security practices, and independently resolve common technical issues or contact IT when needed.
- Must have or obtain a direct, wired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 50 Mbps download and 5 Mbps upload; WiFi and satellite internet are not permitted.
- Must maintain a quiet, secure, private, designated home work location that is tidy, organized, compliant with company and HIPAA guidelines, and free from distractions.
- Must provide workspace furniture, such as a desk or standing desk, and comply with work-from-home requirements.
- Effective verbal and written communication skills.
- Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor.
- Ability to sit for extended periods, talk on the telephone, type, multitask, prioritize, and adapt to a fast-paced changing environment.
- Proficiency with computer skills, including navigating multiple systems and keyboarding.
- Openness to learning new skills as the workplace environment evolves.
Nice To Haves
- At least 2 years of clinical experience in med-surg or a specialty area.
- Managed care experience, especially Utilization Management.
- Bachelor of Science in Nursing (BSN).
Responsibilities
- Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.
- Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations.
- Communicate with providers and other parties to facilitate care and treatment.
- Identify members for referral opportunities to other products, services, or programs.
- Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization.
- Consult with and provide expertise to internal and external constituents regarding utilization and benefit management.
- Navigate multiple computer systems and applications, communicate through digital channels, and troubleshoot common technical issues.
Benefits
- Dental benefits
- Vision benefits
- Wellness resources
- Employee discounts
- Access to certain voluntary benefits
- Other programs supporting colleagues’ physical, emotional, and financial well-being
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What This Job Offers
Job Type
Part-time
Career Level
Mid Level
Education Level
Associate degree
