Job Description

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

• Clinical Audits: Conducts ongoing clinical file reviews of the UM vendor's medical necessity decisions. Audits adverse determination notices for clinical accuracy, ensuring they correctly cite the specific utilized clinical criteria (MCG code, Plan Policies) as required by state and accreditation standards.
• Utilization Review: Identify trends, patterns of over or under-utilization, and potential areas for intervention. Monitor prior authorizations, concurrent reviews (inpatient case management), and retrospective reviews to ensure appropriate care, setting, and length of stay.
• Clinical/Quality Review: Review provider, member, client, and internal queries related to prior authorizations.
• Ensure regulatory compliance: Maintain up-to-date knowledge of and adherence to federal, state, and CMS regulations, as well as accreditation standards. Prepare documentation and process narratives to support NCQA delegation reporting for UM
• Stay up-to-date with relevant UM regulations and industry best practices.
• Ensure UM operations are in compliance with all applicable laws and regulations.
• Assist in the development and implementation of policies and procedures to mitigate regulatory risk.

Stakeholder & Client Communication

• Act as the primary clinical and UM operations liaison for clients and the TPA UM vendor, addressing complex questions and resolving regulatory or policy discrepancies.
• Facilitate cross-functional communication and collaboration with departments such as Clinical Policy, Legal, Compliance, and IT to ensure seamless UM operations. Facilitates consistent patient transitions between internal UM and Care Management teams and ensure linkage between teams.
• Participate in client-facing meetings
• Subject matter expertise: Serve as an internal SME on medical necessity criteria, evidence-based guidelines, accepted standards of medical practice, and prior authorization coding

Qualifications:

• Education: Current, active Registered Nurse (RN) license required. Bachelor of Science in Nursing (BSN) or related field preferred.
• 5-7 years of progressive experience in Utilization Management within a health plan, Managed Care Organization (MCO), or TPA setting. Minimum of 5 years of direct clinical patient care experience.
• In-depth knowledge of UM regulatory requirements, including state/federal mandates, accreditation standards (e.g., NCQA, URAC), and medical necessity criteria. Mastery of coding for prior authorizations
• Demonstrated ability to translate complex regulatory language into clear, executable operational steps and policies.
• Excellent written and verbal communication, presentation, and auditing skills.
• Excellent analytical, problem-solving, and decision-making skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Experience with healthcare technology platforms and data analysis tools.
• Proficiency in analyzing complex clinical documentation and data trends.

Compensation: $45 - $55 per hour

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