Healthcare Consultant III - Utilization Management Clinical Consultant

Job Summary:

• Are you passionate about making a meaningful difference in the lives of patients?
• Join client as a Utilization Management Clinical Consultant and become part of a mission-driven team that’s transforming healthcare for Arizona’s most vulnerable populations.
• In this full-time, remote role, you’ll handle cases within a hospital setting while also managing back-end responsibilities.
• This includes conducting retrospective reviews and analyzing claims after they’ve been assessed.

Work Expectations:

• Must work Client business hours regardless of home time zone.
• Must have a quiet, private home workspace and reliable highspeed internet.
• No scheduled PTO during the first 3 months.

Key Responsibilities:

• Examines the appropriateness and medical necessity of requested healthcare services, such as hospital admissions, procedures, tests, and therapies.
• Applies in-depth knowledge of clinical guidelines, protocols, and evidence-based criteria to assess the necessity and quality of healthcare services.
• Research opportunities to optimize resource utilization, mitigate unnecessary procedures or tests, and promote the use of cost-effective alternatives.
• Provides education and guidance, under close supervision, to healthcare providers regarding utilization management processes, guidelines, and documentation requirements.
• Reviews medical records, analyzes clinical data, and determines if services align with established guidelines and standards.
• Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization of certain healthcare services.
• Conducts routine reviews to monitor the ongoing care of patients during their hospital stay and/or treatment.
• Develops programs that promote quality effectiveness of healthcare services and optimize benefit utilization.
• Completes clinical reports that communicate findings, monitor key performance indicators, and track the effectiveness of utilization management initiatives.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members.
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs or other post discharge programs and facilitates referrals.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Education:

• Associate's degree in nursing (RN) required, BSN preferred.

Required Qualifications:

• Active, unrestricted Arizona RN license or a compact license that includes Arizona.
• 3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

Preferred Qualifications:

• Clinical experience in ER, ICU, or Critical Care preferred.
• Managed Care/Utilization Management experience.
• Demonstrate making thorough independent decisions using clinical judgement.
• Proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.
• Strong clinical judgment & utilization management skills - Ability to apply medicalnecessity criteria, make independent decisions, and coordinate with providers.

Remote Work Expectations:

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.