Med Ops Utilization Management Team Lead- Medicare

CVS Health

18h•$60,522 - $129,615•Onsite

About The Position

We re building a world of health around every individual shaping a more connected, convenient and compassionate health experience. At CVS Health®, you ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger helping to simplify health care one person, one family and one community at a time. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Analyzes reports for assignments/trends/metrics/issues. First in line for questions from frontline staff on cases. May be required to proctor RN/MD rounds. Assists with escalated case reviews/facility issues. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Requirements

3+ years of experience as a Registered Nurse in adult acute care/critical care setting
1+ years of Managed Care Experience
Must have active current and unrestricted RN licensure in state of residence
Drives high-performing teams, increases productivity, and simplifies processes within Medicare Utilization Management
Associates or Bachelors in Nursing OR 3+ years Team Lead Experience

Nice To Haves

Strong communication and presentation skills
BSN preferred but not required with experience
Preference for those residing in CST or MST time zones
Prior Medicare experience
Certified Preceptor

Responsibilities

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
Analyzes reports for assignments/trends/metrics/issues
First in line for questions from frontline staff on cases
May be required to proctor RN/MD rounds
Assists with escalated case reviews/facility issues
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Communicates with providers and other parties to facilitate care/treatment
Identifies members for referral opportunities to integrate with other products, services and/or programs
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
May be called upon to provide float coverage for Team Leads as needed
Assess UMNC efficiency for new job aides, processes, and change initiatives
Partners with Learning & Performance (L&P) on new hire transitions and working to build a consistent mentoring/coaching program for all of our new hires
Leads re-education and action planning
Serves as mentor (approximately four weeks per new hires)
Serves as UM subject matter expert for UM COE project design and stakeholder initiatives impacting workflows or turnaround times
Conducts case lookups and summaries on escalated cases to support senior leaders with member or provider issues