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
Quality Assurance & Regulatory Compliance
Stakeholder & Client Communication
Qualifications:
Compensation: $45 - $55 per hour
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