Utilization Management Nurse Consultant

CVS Health

1d • $32 - $69

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 Must hold Illinois state RN licensure Hours: M-F; 8am - 5pm CST - Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services. - Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function - Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care - Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support) - Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment - Identifies members who may benefit from care management programs and facilitates referral - Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

Requirements

• Must have active, current, and unrestricted RN licensure in state of IL
• Must be available to work M-F; 8am - 5pm CST
• Willingness to obtain additional state licenses
• 3+ years of clinical practice experience in an inpatient setting as an RN
• ASN Required, BSN Preferred

Nice To Haves

• Managed care experience
• Discharge planning experience
• Utilization Management experience

Responsibilities

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
• Identifies members who may benefit from care management programs and facilitates referral
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree