Senior Consultant – Clinical Utilization Management SME

Tria Federal is seeking a Senior Consultant – Clinical Utilization Management SME to provide clinical and utilization-management expertise supporting the Department of Veterans Affairs. The SME will apply utilization-management expertise to assess clinical processes, medical-necessity workflows, referral and authorization processes, care coordination, utilization patterns, and clinical risk.

The ideal candidate is a licensed RN (or other clinical degree / license) with significant experience in utilization management, care management, prior authorization, clinical review, medical necessity, appeals, care coordination, or payer/provider clinical operations.

Responsibilities:

Provide clinical subject matter expertise in utilization management, care management, medical necessity, and clinical review.

Assess referral, authorization, utilization-management, and care-coordination workflows and identify barriers to timely care.

Review clinical and operational processes for opportunities to improve access, quality, appropriateness, cost, and patient outcomes.

Evaluate utilization trends and identify clinical, operational, and process drivers of variation.

Support development and refinement of clinical workflows, protocols, decision support, and standard operating procedures.

Conduct clinical root-cause analysis involving access, utilization, care coordination, denials, medical documentation, and patient-care impacts.

Support evaluation of utilization-management practices across providers.

Develop clinical recommendations and executive-level analyses that clearly articulate patient-care, operational, financial, and compliance impacts.

Collaborate with physicians, nurses, healthcare administrators, network teams, payment SMEs, and VA stakeholders.

Support clinical requirements development, operational readiness, implementation, training, and change-management activities.

Contribute to assessments, white papers, decision papers, risk analyses, and performance frameworks.

Skills & Experience:

7+ years of healthcare clinical operations, utilization management, care management, case management, clinical review, or related experience.

3+ years of direct utilization-management or clinical review experience preferred.

Experience with medical necessity review, prior authorization, concurrent review, retrospective review, appeals, or care management.

Understanding of healthcare payer/provider workflows and clinical documentation.

Ability to translate clinical findings into operational and executive recommendations.

Strong written and verbal communication skills.

Bachelor's degree required; BSN preferred.

Qualifications:

Active, unrestricted Registered Nurse (RN) license.

Medicare Advantage, Medicaid, commercial payer or government payer experience.

InterQual, MCG/Care Guidelines, or comparable clinical decision-support experience.

Utilization-management accreditation or quality experience.

Population health/care management.

Behavioral health, post-acute care, specialty care, emergency care, or high-cost/high-risk population experience.

VA/VHA experience.

CCM, ACM, CPHQ, or similar certification.