Utilization Management Nurse Consultant

CVS Health • Ohio, IL

76d • $26 - $56 • 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 Summary - 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 benefit 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. - UMNC meets set productivity and quality expectations. - Effective communication skills, both verbal and written - Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. - Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. - Work requires sitting for extended periods, talking on the telephone and typing on the computer. - Work from home position: During work hours, Colleagues who are working from home must be available by phone, videoconference, and email in a manner and frequency that is required by the Colleague's Leader. - Colleagues must be available from time to time to come into the office or client location on a given day for work-related meetings, training sessions or other events, as directed by their Leader. - Position is Monday through Friday varying hours available with Holiday, Weekend, and late rotations.

Requirements

• Registered Nurse
• Must have active current and unrestricted RN licensure in state of residence.
• May be required to obtain additional Nursing Licenses as business needs require.

Nice To Haves

• 1+ years of Managed Care Experience
• 1+ years of clinical experience in acute or post-acute setting.

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 benefit 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.
• Meets set productivity and quality expectations.

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access

What This Job Offers

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