Utilization Management Nurse, Consultant

Your Role

The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their family. The FEP Utilization Management Nurse Consultant (Lead) will report to the FEP Utilization Management Medical Review Manager. In this role you will be part of a dynamic team responsible for prior authorization, concurrent, and post service medical reviews. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit. Ultimately contributing to decreasing the cost of healthcare.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• Previous experience in utilization management preferred
• Strong computer skills related to Windows-based programs and applications
• Varied acute care clinical background
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
• Strong clinical documentation skills, independent problem identification and resolution skills
• Excellent analytical and problem-solving skills
• Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)
• Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision
• Work is performed with limited oversight