Utilization Management Nurse Consultant

CVS Health

1d•Onsite

About The Position

CVS Health is building a world of health around every individual, shaping a more connected, convenient, and compassionate health experience. Colleagues are passionate, innovative, accountable, and prioritize safety and quality. The Utilization Management Nurse Consultant role is part of a 24/7 operation, with work schedules including weekends, holidays, and evening hours. The consultant 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. This involves gathering clinical information, applying criteria/guidelines, and clinical judgment to make coverage determinations. The role requires communication with providers and other parties, identifying referral opportunities, promoting quality effectiveness of Healthcare Services and benefit utilization, and consulting with internal and external constituents on utilization/benefit management. The position operates in a typical office environment with productivity and quality expectations, requiring close inspection of documents and PC monitors, sedentary work, extended periods of sitting, talking on the telephone, and typing on a computer. The ability to multitask, prioritize, adapt to a fast-paced environment, and proficiency with computer skills (navigating multiple systems, keyboarding) are essential, along with effective verbal and written communication.

Requirements

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Must have active current and unrestricted RN licensure in state of residence
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
Associates Degree required

Nice To Haves

2+ years of clinical experience required in med surg or specialty area
Managed Care experience preferred, especially Utilization Management
Preference for those residing in ET, CT 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