California Licensed Clinical Consultant

Job Summary

Providing clinical and utilization management expertise, the remote Senior Consultant - Clinical Utilization Management SME will assess clinical processes and workflows, identify barriers to care, and develop recommendations to improve patient outcomes and operational efficiency.

Key responsibilities:

• Provide clinical subject matter expertise in utilization management and care coordination
• Assess and improve referral, authorization, and care-coordination workflows
• Conduct clinical root-cause analyses and support the development of clinical protocols and decision support

Required qualifications:

• Active, unrestricted Registered Nurse (RN) license
• 7+ years of experience in healthcare clinical operations or utilization management
• Experience with medical necessity review and prior authorization processes
• Understanding of healthcare payer/provider workflows
• Bachelor's degree required; BSN preferred