Utilization Management Nurse Consultant

CVS Health•Work At Home-Virginia, VA

4d•$26 - $62•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Precertification Nurse: Special Case Precert Unit Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours 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.

Requirements

3+ years of experience as a Registered Nurse
Must have active current and unrestricted RN licensure in state of residence
1+ years of Med/Surg experience
1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
Must be willing and able to work Monday through Friday, 9:00am to 6pm EST. with occasional holiday rotation.
Rotational on-call may be required after hours to assist with emergency out of country emergency admissions.

Nice To Haves

Prior Authorization or Utilization Management experience
Managed care experience
Experience using MedCompass
Ambulatory surgery experience

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.