Utilization Management Nurse Consultant

CVS Health•Work At Home-Ohio, OH

3d•$26 - $69•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. Fully remote with requirement to work the following schedule: Monday-Friday 8:00am-4:30pm EST. Position Summary As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.

Requirements

Must have active, current, and unrestricted RN licensure in state of residence
Must be available to work Monday through Friday 8:00am - 4:30pm EST
Must be willing to work weekend rotation, approximately every 6 weeks
Holiday rotation per the need of the department (typically 1 holiday per year)
3+ years of clinical RN experience
1+ years of experience using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Nice To Haves

1+ years’ experience Utilization Review experience
1+ years’ experience Managed Care
Strong communication skills
Ability to manage multiple priorities, effective organizational and time management skills required
Experience in healthcare utilization management, critical care, emergency department, or case management

Responsibilities

Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
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.