Utilization Management Nurse Consultant, EST Zone

September 19, 2026 Auto Import

Job Description:

Use your clinical background to coordinate, document, and communicate all aspects of the utilization and benefit management process
Ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times
Review clinical documentation, collaborating with providers, and supporting high-quality, cost‑effective care
Review services for medical necessity and appropriate benefit use
Facilitate efficient discharge planning
Collaborate with providers and facilities to support members with complex needs
Collect and evaluate clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations
Communicate with providers and external partners to coordinate care and treatment plans
Identify opportunities for referrals to additional programs, services, or care solutions
Recognize opportunities to promote quality care delivery and effective benefit utilization
Serve as a resource to internal and external stakeholders regarding UM processes and clinical considerations

Requirements:

Active, unrestricted RN license
2+ years of acute hospital clinical experience (strong preference for medical‑surgical, ICU, behavioral health or other specialty area)
Strong clinical assessment and decision‑making abilities
Excellent organizational skills with the ability to manage multiple priorities
Ability to work independently and communicate effectively via phone
Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls
1+ year of Utilization Review experience (preferred)
1+ year of Managed Care experience (preferred)
Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) (preferred)
Strong telephonic communication skills (preferred)

Benefits: