Utilization Management Clinical Nurse Consultant - Prior Authorization
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 Summary: The Utilization Management Clinical Nurse Consultant - Prior Authorization utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
Requirements
- 3+ years of experience in clinical practice.
- Ability to work 10-hour shifts, 4-days per week, with rotating days (including some weekends & holidays), supporting Arizona Time Zone.
- Must have an active and unrestricted RN (Registered Nurse) licensure in the state of Arizona or Compact RN licensure.
Nice To Haves
- Resides in one of the following time zones: MST (Mountain Standard Time), AZ (Arizona), or PST (Pacific Standard Time).
- Previous experience with prior authorization.
- Previous experience with utilization management.
- Previous experience in an acute care setting.
- Previous clinical experience in Emergency Department, Home Health, ICU (Intensive Care Unit), Telemetry, or Medical/Surgical.
- Bachelors of Science in Nursing.
Responsibilities
- 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 and 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.
- For more information, visit https://jobs.cvshealth.com/us/en/benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
