Utilization Management Nurse Consultant

CVS Health

15h•Onsite

About The Position

CVS Health is building a world of health around every individual, aiming to shape a more connected, convenient, and compassionate health experience. Colleagues are passionate, innovative, accountable, and prioritize safety and quality. This role is part of a 24/7 Utilization Management operation, requiring work schedules that include weekends, holidays, and evening hours. The Utilization Management Nurse 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 clinical criteria/guidelines, policies, procedures, and clinical judgment to make coverage determinations. The consultant communicates with providers and other parties to facilitate care, identifies members for referral opportunities to integrate with other products/services, and seeks opportunities to enhance the quality and effectiveness of Healthcare Services and benefit utilization. They also consult and provide expertise to internal and external stakeholders in managing utilization and benefits. The position involves a typical office working environment with productivity and quality expectations, requiring close inspection of documents, PC monitor use, and sedentary work including extended periods of sitting, talking on the telephone, and typing on a computer. The role demands multitasking, prioritization, adaptability to a fast-paced environment, and proficiency with computer skills, including navigating multiple systems and keyboarding, along with effective verbal and written 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 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

Nice To Haves

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

Responsibilities

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
Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Communicate with providers and other parties to facilitate care/treatment
Identify members for referral opportunities to integrate with other products, services and/or programs
Identify opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function