Utilization Review Nurse

Clinical Utilization Management Program Specialist (Registered Nurse)

The Senior Utilization Management Consultant is a highly experienced Registered Nurse responsible for ensuring the compliant, efficient, and high-quality operation of Utilization Management (UM) programs. This role serves as the internal expert on federal and state regulatory requirements, translating medical policy into actionable operational procedures. The Consultant drives quality assurance, performs audit oversight of UM processes, and acts as the primary clinical liaison between the organization and external clients or Third-Party Administrator (TPA) vendors. This critical role is responsible for maintaining clinical integrity, ensuring policy adherence, and performing targeted quality audits across our diverse client base with an additional focus on regulatory consistency. This position does not involve direct staff management but requires strong cross-functional leadership and client communication skills.

Key Responsibilities

Clinical and Operational Oversight & Policy

• Operationalize medical policy by collaborating with the UM program manager, clients, UM vendor(s) and internal CH teams to formally adopt, operationalize, and update policies.
• Drive process improvements and efficiencies within UM operations, ensuring standards are consistently met.
• Work with cross-functional teams to integrate new policies or regulatory changes into existing technological systems and workflows.
• Maintain and manage the accuracy of the prior authorization code list, ensuring alignment with current medical policy and regulatory requirements
• Maintains documentation for audits, annual program evaluation to ensure policies and practice meet regulatory and clinical integrity requirements.

Quality Assurance & Regulatory Compliance

Stakeholder & Client Communication

Qualifications :

Compensation : $45 - $55 per hour