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.