Utilication Management Nurse Consultant

US Tech Solutions; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player seeks a skilled clinical evaluator to ensure compliance with regulatory standards and enhance healthcare management services. In this role, you will review clinical documentation, evaluate quality of care issues, and coordinate clinical resolutions with internal and external clinicians. Your expertise will help navigate complex clinical criteria and benefit plans while ensuring adherence to accreditation requirements. Join a forward-thinking company that values your clinical insights and offers opportunities for professional growth in a dynamic healthcare environment.

Qualifications

• Minimum of 3 years of clinical experience required.
• Managed Care/Medicare experience preferred.

Responsibilities

• Reviews documentation to evaluate quality of care issues based on clinical policies.
• Accurately applies review requirements to ensure compliance with guidelines.
• Condenses complex information into clear clinical pictures.

Skills

Clinical Evaluation

Regulatory Compliance

Data Analysis

Clinical Documentation

Managed Care Knowledge

Education

Registered Nurse (RN) License

Job description

Position Summary:

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Responsibilities:

1. Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. Data gathering requires navigation through multiple system applications. Staff may be required to contact providers of record, vendors, or internal Healthcare departments to obtain additional information.
2. Evaluates documentation/information to determine compliance with clinical policy, regulatory, and accreditation guidelines.
3. Accurately applies review requirements to ensure cases are reviewed by a practitioner with clinical expertise for the issue at hand.
4. Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy, and other processes necessary to support the review of clinical documentation/information.
5. Proactively and consistently applies regulatory and accreditation standards to ensure activities are reviewed and processed within guidelines.
6. Condenses complex information into a clear and precise clinical picture while working independently. Reports audit or clinical findings to appropriate staff or others to ensure appropriate outcomes and follow-up for improvement as needed.

Experience

• Minimum of 3 years of clinical experience required; Managed Care/Medicare experience preferred.

Additional Responsibilities:

• Provide comprehensive healthcare management services to facilitate appropriate treatment, effectively manage healthcare costs, and improve operational efficiency related to clinical issues.

Education

• RN with current, unrestricted state licensure.

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To learn more, visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.