Utilization Management Clinical Consultant (Remote-Arizona)

CVS Health•Work At Home-Arizona, AZ

1d•$29 - $62•Remote

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. 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 Skilled Nursing Facility 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, SNF, alternative care setting such as home health or ambulatory care required.
Associate's degree in nursing (RN) required

Nice To Haves

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

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.