Utilization Management Nurse Consultant

CVS Health

1d • $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. Position Summary Work at home with strong preference for those residing in EST or CST. Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. Required schedule: Tuesday - Saturday 9:30am -6pm EST/CST. - 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 hold active and unrestricted RN licensure in state of residence
• 3+ years of Med/Surg experience
• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)

Nice To Haves

• Candidates residing in EST or CST zone strongly preferred.
• Experience Medicare/Medicaid populations
• Previous Utilization Management experience
• MCG experience
• Managed care experience
• UM Certification
• MedCompass 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

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

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