Utilization Management Nurse Consultant

CVS Health • Home, PA

338d • $29 - $62

About The Position

Utilization Management is a 24/7 operation and work schedules may include weekends, holidays, and evening hours. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You will utilize 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. This role involves gathering clinical information and applying the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. You will communicate with providers and other parties to facilitate care/treatment and identify members for referral opportunities to integrate with other products, services and/or programs. Additionally, you will identify opportunities to promote quality effectiveness of Healthcare Services and benefit utilization, and consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. The typical office working environment has productivity and quality expectations, requiring the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. The work is sedentary, involving periods of sitting, talking, and listening, and requires proficiency with computer skills, effective communication skills, both verbal and written.

Requirements

• 3+ years of experience as a Registered Nurse.
• Must have active current and unrestricted RN licensure in state of residence.
• 1+ years of clinical experience in acute or post-acute setting.
• Utilization management is a 24/7 operation. Work schedules will include a minimum of 6 weekend rotations per year, as well as holidays and evening rotations.

Nice To Haves

• 3+ years of clinical experience required.
• Managed Care experience preferred.

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.
• 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.

Benefits

• Full range of medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan.
• Fully-paid term life insurance plan.
• Short-term and long-term disability benefits.
• Numerous well-being programs.
• Education assistance.
• Free development courses.
• CVS store discount.
• Discount programs with participating partners.
• Paid Time Off (PTO) or vacation pay.
• Paid holidays throughout the calendar year.

What This Job Offers

• Job Type: Full-time
• Industry: Health and Personal Care Retailers
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees