Utilization Management Nurse Consultant

CVS Health

1d•Remote

About The Position

This is a fulltime remote Utilization Management Nurse Consultant opportunity. Utilization management is a 24/7 operation, and work schedules may include weekends, holidays, and evening rotations. The role involves 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. The consultant will gather clinical information and apply appropriate clinical criteria/guidelines, policy, procedure, and clinical judgment to render coverage determinations/recommendations across the continuum of care. Communication with providers and other parties is essential to facilitate care/treatment. The position also identifies members for referral opportunities to integrate with other products, services, and programs, and seeks opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Furthermore, the consultant will lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. The typical working environment is an office setting 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 the computer. The ability to multitask, prioritize, and adapt to a fast-paced changing environment is crucial, along with proficiency in computer skills and effective communication.

Requirements

Active current and unrestricted RN licensure in state of residence
3+ years of experience as a Registered Nurse
1+ years of clinical experience in acute or post-acute setting
Ability to work Monday - Friday 8:00am-5:00pm EST with late night rotation 10:30 - 7pm EST
Ability to work weekends, holidays and evening rotations
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 sit for extended periods, talking on the telephone and typing on the computer
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

Experience working in ER, Med/Surg, and/or Critical care setting
Managed Care experience
Utilization review experience
Experience working with MS office applications such as Teams, Outlook, Excel, and Word
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 across 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