Utilization Management Nurse Consultant

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Utilization Management Nurse Consultant based in Canada.

We are seeking an experienced Registered Nurse to join a remote Utilization Management team in a non-bedside clinical role. You will use your nursing expertise and evidence-based clinical criteria to review cases, assess medical necessity, and support appropriate coverage decisions. Working closely with healthcare providers and interdisciplinary teams, you will help ensure members receive the right care in the right setting at the right time.

Your clinical judgment will contribute to effective prior authorization decisions, improved healthcare quality, and better member outcomes. You will also serve as a trusted clinical resource, helping stakeholders navigate complex cases and treatment planning. This opportunity is ideal for a detail-oriented nursing professional who wants to apply their clinical knowledge in a structured, collaborative, and quality-focused remote environment.

• Review clinical documentation and patient cases to make utilization management and coverage determinations using established, evidence-based criteria.

• Apply clinical assessment skills and professional nursing judgment to evaluate medical necessity and support prior authorization decisions.

• Collaborate with healthcare providers and interdisciplinary care teams to facilitate appropriate treatment planning and care coordination.

• Ensure members receive appropriate care in the right setting and at the right time while supporting quality and safety standards.

• Identify opportunities to improve clinical outcomes, operational processes, and the overall member experience.

• Act as a clinical resource for internal colleagues, external providers, and other relevant stakeholders.

• Navigate multiple healthcare applications and digital platforms to review documentation, record decisions, and manage cases efficiently.

• Maintain confidentiality and comply with applicable healthcare privacy, security, and remote-work requirements.

• Work a regular Monday-to-Friday schedule, with flexibility to support occasional evenings, weekends, or holidays based on operational needs.

• Active, unrestricted Registered Nurse (RN) license in the state of residence, as specified in the role requirements.

• Minimum of 3 years of professional RN experience.

• Associate Degree in Nursing (ADN) required; a Bachelor of Science in Nursing (BSN) is preferred.

• Strong clinical assessment, critical thinking, problem-solving, and decision-making skills.

• Ability to interpret clinical information, apply evidence-based criteria, and make sound utilization management decisions.

• Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.

• Ability to work Monday through Friday, from 9:00 AM to 5:30 PM in the local time zone, with occasional schedule flexibility due to the 24/7 nature of utilization management operations.

• Previous experience in utilization management, prior authorization, care management, or managed care is preferred.

• At least 1 year of Medical-Surgical Nursing experience is preferred.

• Familiarity with Med Compass or similar utilization management platforms is an advantage.

• Ambulatory surgery or outpatient clinical experience is beneficial.

• Strong digital skills, including the ability to navigate multiple monitors, applications, calendars, email systems, and virtual meeting platforms simultaneously.

• Experience with Microsoft 365 tools, including Teams, Outlook, Word, Excel, and PowerPoint, or equivalent applications.

• Ability to securely access healthcare systems and applications, including VPNs, and follow established data protection…