Utilization Management Nurse Consultant

CVS Health

1d•Remote

About The Position

This Utilization Management (UM) Nurse Consultant role is fully remote and employee can live in any state. At CVS Health, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do. The position is responsible for helping to simplify health care one person, one family and one community at a time. 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

RN with active and unrestricted state licensure
2+ years of clinical experience as an RN (all clinical areas considered: Home Health, Med/Surg, Telemetry, ICU, NICU, Long term care, orthopedics, and more)

Nice To Haves

1+ years’ experience Utilization Review experience
1+ years’ experience Managed Care
Strong telephonic communication skills
1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
Experience with computers toggling between screens while using a keyboard and speaking to customers.
Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills
Ability to manage multiple priorities, effective organizational and time management skills required
Ability use a computer station and sit for extended periods of time

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.