Utilization Management Clinical Consultant (Remote-Arizona)

CVS Health

13d • $29 - $62 • Remote

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Information Schedule: Monday–Friday 8:00am-5:00pm AZT (No weekends or holidays) Location: 100% Remote (Must have Arizona RN license or compact license that includes Arizona.) Candidate may have opportunities to travel for occasional staff events as needed. Position Summary Are you passionate about making a meaningful difference in the lives of patients? Join Mercy Care as a Utilization Management Clinical Consultant and become part of a mission-driven team that’s transforming healthcare for Arizona’s most vulnerable populations. In this full-time, remote role, you’ll handle cases within a hospital setting while also managing back-end responsibilities. This includes conducting retrospective reviews and analyzing claims after they’ve been assessed.

Requirements

• Active, unrestricted Arizona RN license or a compact license that includes Arizona.
• 3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Nice To Haves

• Clinical experience in ER, ICU, or Critical Care preferred.
• Managed Care/Utilization Management experience.
• Experience with Claims Review processes
• Demonstrate making thorough independent decisions using clinical judgement.
• Proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.

Responsibilities

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members.
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs or other post discharge programs and facilitates referrals.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees