Utilization Management Nurse Consultant

Accountabilities: Review clinical documentation and patient cases to make utilization management and coverage determinations using established, evidence-based criteria. Apply clinical assessment skills and professional nursing judgment to evaluate medical necessity and support prior authorization decisions. Collaborate with healthcare providers and interdisciplinary care teams to facilitate appropriate treatment planning and care coordination. Ensure members receive appropriate care in the right setting and at the right time while supporting quality and safety standards. Identify opportunities to improve clinical outcomes, operational processes, and the overall member experience. Act as a clinical resource for internal colleagues, external providers, and other relevant stakeholders. Navigate multiple healthcare applications and digital platforms to review documentation, record decisions, and manage cases efficiently. Maintain confidentiality and comply with applicable healthcare privacy, security, and remote-work requirements. Work a regular Monday-to-Friday schedule, with flexibility to support occasional evenings, weekends, or holidays based on operational needs. Requirements: Active, unrestricted Registered Nurse (RN) license in the state of residence, as specified in the role requirements. Minimum of 3 years of professional RN experience. Associate Degree in Nursing (ADN) required; a Bachelor of Science in Nursing (BSN) is preferred. Strong clinical assessment, critical thinking, problem-solving, and decision-making skills. Ability to interpret clinical information, apply evidence-based criteria, and make sound utilization management decisions. Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel. Ability to work Monday through Friday, from 9:00 AM to 5:30 PM in the local time zone, with occasional schedule flexibility due to the 24/7 nature of utilization management operations. Previous experience in utilization management, prior authorization, care management, or managed care is preferred. At least 1 year of Medical-Surgical Nursing experience is preferred. Familiarity with MedCompass or similar utilization management platforms is an advantage. Ambulatory surgery or outpatient clinical experience is beneficial. Strong digital skills, including the ability to navigate multiple monitors, applications, calendars, email systems, and virtual meeting platforms simultaneously. Experience with Microsoft 365 tools, including Teams, Outlook, Word, Excel, and PowerPoint, or equivalent applications. Ability to securely access healthcare systems and applications, including VPNs, and follow established data protection procedures. Basic technical troubleshooting skills, including resolving connectivity and application issues, with a willingness to learn new technologies. For remote work, candidates must have a direct wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite connections are not accepted. Must maintain a dedicated, private workspace that complies with HIPAA and applicable security requirements. Must be able to work from the confirmed state and city of residence and maintain the required internet speeds and remote-work standards. Company-provided equipment includes a computer, monitor(s), keyboard, and headset; employees are responsible for providing appropriate workspace furniture. Benefits: Fully remote, work-from-home opportunity. Full-time schedule of 40 hours per week. Competitive base pay range of $29.10–$62.32 per hour , depending on experience, education, location, and other relevant factors. Eligibility for a bonus, commission, or short-term incentive program in addition to base compensation. Comprehensive benefits package, subject to eligibility, including: Medical, dental, and vision coverage. Paid time off. Retirement savings options. Wellness programs and additional resources supporting physical, emotional, and financial well-being. Company-provided computer, monitor(s), keyboard, and headset. Additional information about benefit options is provided during the application process.