Utilization Management Nurse Consultant NICU Must be RN Licensed in TX

Aetna Medicaid Administrators

50d • $29 - $62

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 Schedule for this position is 8:00 - 5:00 PM CST with rotating Weekends As a NICU UMNC, you'll leverage your neonatal clinical expertise to review, assess, and coordinate care for neonatal intensive care unit (NICU) cases. You'll ensure medically necessary and cost-effective care by applying clinical guidelines, collaborating with providers, and supporting our commitment to quality outcomes for our youngest patients.

Requirements

• Must have active, current and unrestricted RN licensure in TX
• 5 years of recent NICU nursing experience
• Must be willing and able to work Monday - Friday 8 am - 5 pm CST with occasional weekend/holiday on-call
• Position requires proficiency with computer skills which includes navigating multiple systems
• Ability to work in a fast paced environment

Nice To Haves

• Certification in Neonatal Intensive Care Nursing (RNC-NIC) or Utilization Review
• Prior experience in managed care or health plan setting
• Demonstrated ability to work independently and collaboratively

Responsibilities

• Conduct clinical reviews of NICU requests for medical necessity, appropriateness, and level of care using evidence-based criteria
• Collaborate with healthcare providers, case managers, and families to optimize care pathways
• Ensure compliance with regulatory and organizational standards
• Provide education and support regarding utilization management processes to colleagues and providers
• Document clinical determinations and rationales in accordance with policy
• Participate in quality improvement initiatives and interdisciplinary meetings as needed
• Strong critical thinking, communication, and organizational skills
• Proficiency with electronic medical records and utilization review systems

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