Medicare Predetermination Utilization Management Nurse Consultant

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The Medicare Predetermination Utilization Management Nurse Consultant position involves utilizing 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.

Responsibilities

• 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.

Required Qualifications

• 3+ years of experience as a Registered Nurse.
• Active current and unrestricted RN licensure in state of residence.
• 1+ years of Med/Surg experience.
• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel).
• Must be willing and able to work Saturday, Sunday, Monday and Tuesday 10 hr shifts after approx 4-5 months of training Monday - Friday 7:30am-6pm EST with occasional holiday rotation.

Preferred Qualifications

• Prior Authorization or Utilization Management experience.
• Managed care experience.
• Experience using MedCompass.
• Ambulatory surgery experience.
• Medicare experience is a must.

Education

• Associates degree required.
• BSN preferred.

Benefits

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.

Pay Range

• $26.01 - $68.55