Healthcare Consultant III - Utilization Management Clinical Consultant

Job Title: Healthcare Consultant III - Utilization Management Clinical Consultant Job Location: Fully Remote Job Duration: 6 Months (possibility of extension) Shift: Monday

• Friday, 8:30am
• 5:00pm (Client Time) Payrate: $37.13/ hr. on w2 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.