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 families. 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, it contributes to decreasing the cost of healthcare.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

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

• 4 years clinical experience preferred

• Previous experience in utilization management preferred
• Strong computer skills related to MS Suite
• 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 screen to document the decision
• Work is performed with limited oversight