Utilization Management Nurse Consultant

We're building a world of health around every individual , shaping a more connected, convenient, and compassionate health experience.

As a Utilization Management Nurse Consultant, you will leverage your clinical expertise to review, coordinate, and manage healthcare services for members, ensuring the right care is delivered at the right time and in the most appropriate setting.

Responsibilities:

• Review clinical documentation and apply medical necessity criteria, policies, and clinical guidelines to make coverage determinations and recommendations.
• Coordinate and communicate all aspects of utilization and benefit management activities across the continuum of care.
• Collaborate with providers, healthcare teams, and internal stakeholders to facilitate appropriate treatment plans, discharge planning, and care transitions.
• Utilize critical thinking and clinical judgment to support evidence-based care and appropriate resource utilization.
• Identify members who may benefit from care management programs and facilitate referrals as appropriate.
• Support urgent and emergent member needs, including triage and crisis intervention when necessary.
• Serve as a clinical resource and consultant for internal and external partners regarding utilization management processes and decisions.
• Promote quality improvement initiatives and identify opportunities to enhance healthcare outcomes and benefit utilization.

Requirements:

• Active, unrestricted Registered Nurse (RN) license in the state of Florida.
• Minimum of 3 years of recent inpatient clinical nursing experience.
• Ability and willingness to obtain additional state nursing licenses as needed (company-sponsored).
• Must permanently reside in Florida.
• Strong clinical assessment, documentation, communication, and critical-thinking skills.

Preferred Qualifications:

• Previous Utilization Management (UM) experience.
• Managed Care experience.
• Discharge planning and care coordination experience.
• Experience applying medical necessity guidelines and utilization review criteria.

Education:

• Associate Degree in Nursing (ADN) required.
• Bachelor of Science in Nursing (BSN) preferred.

Benefits: This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Pay Range: $29.10 - $62.32