The Utilization Management Nurse Consultant utilizes clinical skills to assess, plan, and coordinate appropriate healthcare services and benefits for members by gathering clinical information and applying appropriate guidelines to render coverage determinations. This role involves communicating with providers to facilitate care and identifying opportunities to integrate members into other services or promote quality effectiveness of healthcare services.

The UM Nurse Consultant utilizes clinical skills in a collaborative process to assess, plan, coordinate, and evaluate options to facilitate appropriate healthcare services and benefits for members. This involves gathering clinical information, applying appropriate criteria/guidelines, and communicating with providers to facilitate care and identify opportunities for quality improvement.

The Utilization Management Nurse Consultant performs high-acuity, timely, and comprehensive clinical reviews for prior authorization, collaborating with providers and internal teams to ensure medically appropriate and efficient care. Key duties include performing prior authorization reviews using evidence-based criteria, ensuring alignment with regulatory standards, and communicating clinical decisions clearly to stakeholders.

The analyst is responsible for the application and integration of information technology in healthcare, serving as a liaison between IT and operations to align system design with operational processes. This includes data collection, workflow analysis, system configuration, testing, deployment participation, and ensuring software builds meet organizational goals and mandates.