Utilization Management Nurse Consultant

Aetna Medicaid Administrators

3d • $29 - $62 • Remote

About The Position

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary This Utilization Management Nurse Consultant (UMNC) position is 100% remote. As a Utilization Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program and our plan sponsor(s). You would be responsible for ensuring the member is receiving the appropriate care, at the appropriate time, and at the appropriate location using designated criteria, while adhering to federal and state regulated turn-around times. This includes reviewing written and electronic clinical records. We are looking for someone who is highly motivated, detail-oriented, highly organized, and works well in a team environment. Through the use of clinical tools and information/data review, the UM Nurse Consultant 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 complex needs of the member.

Requirements

• Must have active current and unrestricted RN license in state of residence
• Minimum of 3 years of acute hospital clinical experience as an RN
• Ability to use a computer station with multiple screens, operate multiple programs simultaneously, and sit for extended periods of time
• A private designated workspace free of distractions and high-speed internet
• Must be willing and able to work Monday-Friday 8am-5pm EST with occasional weekend on-call and holiday rotation.

Nice To Haves

• Candidate must possess strong customer service skills including attention to customers, sensitivity to certain issues and proactive identification/resolution of issues.
• Experience with all types of Microsoft Office including PowerPoint, Excel, and Word
• Strong telephonic communication skills
• 1+ years of Utilization Review experience
• 1+ years of Managed Care experience

Responsibilities

• coordinate, document and communicate all aspects of the utilization/benefit management program and our plan sponsor(s)
• ensuring the member is receiving the appropriate care, at the appropriate time, and at the appropriate location using designated criteria, while adhering to federal and state regulated turn-around times
• reviewing written and electronic clinical records
• reviews services to assure medical necessity
• applies clinical expertise to assure appropriate benefit utilization
• facilitates safe and efficient discharge planning
• works closely with facilities and providers to meet complex needs of the member

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