Utilization Management Nurse Consultant - Florida

CVS Health•Gainesville, FL

2d•$29 - $62•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 Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. This role is work from home anywhere in the state of Florida. Applicant must reside in Florida. 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

3+ years of clinical practice experience in an inpatient setting required
Must have active current and unrestricted RN licensure in state of Florida
Willingness to obtain additional state licenses as needed (paid for by company)
Must reside in Florida

Nice To Haves

Previous Utilization Management and/or Managed Care experience preferred
Discharge planning 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