Quality Management Nurse Consultant - Remote | Wfh

Are you passionate about making a positive impact on patient care while utilizing your clinical expertise? We have an amazing opportunity for a talented Utilization Management Nurse Consultant to join our dynamic team. In this role, you'll play a vital part in the review and evaluation of clinical information, ensuring quality care and compliance with regulatory and accreditation requirements. Join us in our mission to provide exceptional healthcare solutions that transform lives!
Key Responsibilities
Review and evaluate clinical information and documentation with utmost attention to detail and quality.
Interpret data obtained from clinical records or systems, applying appropriate clinical criteria and policies.
Coordinate clinical resolutions independently, collaborating with internal and external clinicians for support when needed.
Assess potential quality of care issues based on clinical policies and benefit determinations.
Develop determinations or recommendations by considering all documented system information and additional records/data presented.
Navigate through multiple system applications to gather necessary data.
Communicate with providers, vendors, or internal departments to obtain additional information as required.
Evaluate documentation/information to ensure compliance with clinical policy, regulatory guidelines, and accreditation standards.
Apply review requirements accurately, directing cases to practitioners with relevant clinical expertise.
Demonstrate comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy, and other relevant processes.
Proactively apply regulatory and accreditation standards to review and process activities within guidelines.
Condense complex information into a clear and precise clinical picture while working independently.
Report audit or clinical findings to appropriate staff or stakeholders, contributing to improved outcomes and follow-up measures.
Qualifications
Registered Nurse (RN) with an unrestricted active license.
2-3 years of clinical experience, preferably in a Managed Care setting.
Strong understanding of healthcare processes, clinical policies, and benefit plan structures.
Exceptional ability to navigate multiple system applications and gather relevant data.
Proven track record of accurately applying review requirements and clinical criteria.
Detail-oriented with the ability to condense complex information into a clear and concise clinical picture.
Excellent communication skills to collaborate effectively with internal and external stakeholders.
Demonstrated commitment to regulatory compliance and adherence to accreditation standards.
If you are an ambitious and driven healthcare professional seeking a challenging yet rewarding role, this is the perfect opportunity for you. Join our dedicated team and contribute to shaping the future of healthcare!
Employment Type: Contractor
Salary: $ 35.00 37.00 Per Hour