UM Nurse Consultant - Prior Authorization

About the position Responsibilities • Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. • Review clinical records to ensure compliance with federal and state regulations regarding turnaround times. • Confirm medical necessity of services and apply clinical expertise for appropriate benefit utilization. • Facilitate safe and efficient discharge planning in collaboration with healthcare facilities and providers. • Gather clinical information and apply appropriate clinical criteria, guidelines, and policies to make coverage determinations. • Communicate with providers and other parties to facilitate care and treatment for members. • Identify members for referral opportunities to integrate with other products, services, and programs. • Promote quality effectiveness of healthcare services and benefit utilization. • Consult with internal and external stakeholders regarding the utilization/benefit management function. Requirements • Active and unrestricted RN licensure. • 3+ years of Nursing experience. Nice-to-haves • Prior authorization utilization experience highly preferred. • Outpatient Clinical experience. • Knowledge of Medicare/Medicaid. • Managed care experience. • Med Compass Experience. • UM Certification. Benefits • Full range of medical, dental, and vision benefits. • 401(k) retirement savings plan. • Employee Stock Purchase Plan. • Fully-paid term life insurance plan. • Short-term and long-term disability benefits. • Numerous well-being programs. • Education assistance and free development courses. • CVS store discount and discount programs with participating partners. • Paid Time Off (PTO) and paid holidays throughout the calendar year. Apply tot his job Apply To this Job