Utilization Management Nurse Consultant

CVS Health

2d•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. The role is part of a larger effort to simplify healthcare. The Utilization Management department operates 24/7, and work schedules for this position will include weekends, holidays, and evening hours. 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. This includes gathering clinical information, applying criteria/guidelines, and communicating with providers to facilitate care. The position also identifies referral opportunities and promotes quality effectiveness of healthcare services and benefit utilization. It involves consulting with internal and external constituents on utilization/benefit management. The work environment is a typical office setting with productivity and quality expectations, requiring close inspection of documents, extended periods of sitting, talking on the telephone, typing on a computer, multitasking, prioritizing, and adapting to a fast-paced environment. Proficiency with computer skills, including navigating multiple systems and keyboarding, and effective verbal and written communication skills are essential.

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 work schedules that include weekends, holidays, and evening hours due to Utilization Management being a 24/7 operation

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 CST/EST zones

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