Utilization Management Nurse Consultant

CVS Health•Paris, SC

1d•Onsite

About The Position

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. The position requires utilizing 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 involves gathering clinical information and applying appropriate clinical criteria/guidelines, policy, procedure, and clinical judgment to render coverage determinations/recommendations along the continuum of care. The consultant will communicate with providers and other parties to facilitate care/treatment, identify members for referral opportunities to integrate with other products, services, and/or programs, and identify opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. They will also consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. The role operates in a typical office working environment with productivity and quality expectations, requiring close inspection of documents, sedentary work, extended periods of sitting, talking on the telephone, typing on the computer, multitasking, prioritizing, adapting to a fast-paced environment, and proficiency with computer skills and effective communication.

Requirements

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Active current and unrestricted RN licensure in state of residence
Ability to perform close inspection of hand written and computer generated documents as well as a PC monitor
Sedentary work involving periods of sitting, talking, listening
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written
Associate Degree required

Nice To Haves

2+ years of clinical experience in med surg or specialty area
Managed Care experience preferred, especially Utilization Management
Preference for those residing in EST zones
BSN 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