Utilization Management Nurse Consultant

CVS Health

3d • $29 - $62

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. Medicare Clinical Predetermination Nurse Must be willing and able to work Monday through Friday, 9am - 6:00 pm EST or CST with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours. 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 have active current and unrestricted RN licensure in state of residence
• 1+ years of Med/Surg experience
• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
• Must be willing and able to work Monday through Friday, 9:00am to 6:00 pm eastern or central time with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

Nice To Haves

• Prior Authorization or Utilization Management experience
• Managed care experience
• Experience using MedCompass
• Ambulatory surgery experience
• BSN preferred

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

• 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
• Number of Employees: 5,001-10,000 employees