RN- Utilization Management Clinical Consultant- Remote

Job Title : RN- Utilization Management Clinical Consultant- Remote

Duration: 6 Plus month with possible extension

Location: Fully Remote

Pay Range: $36- $39.00/hr

Primary Duties & Responsibilities:

• Review clinical information and apply medical necessity criteria, clinical guidelines, policies, and professional judgment to render coverage determinations and discharge planning decisions.

• Analyze medical records and clinical data to ensure services align with evidence-based standards and quality benchmarks.

• Coordinate and communicate with healthcare providers, internal teams, and external stakeholders to facilitate timely, appropriate care and authorization decisions.

• Conduct concurrent reviews to monitor ongoing inpatient or outpatient treatment and support continuity of care.

• Identify members who may benefit from care management programs and facilitate appropriate referrals.

• Provide urgent or emergent clinical interventions when required, including triage and crisis support.

• Identify opportunities to optimize resource utilization, reduce unnecessary services, and promote cost-effective, high-quality care.

• Educate providers, under appropriate supervision, on utilization management processes, documentation requirements, and applicable guidelines.

• Prepare clinical reports and documentation to communicate findings, monitor key performance indicators, and track utilization management outcomes.