Utilization Management Nurse Consultant

CVS Health

1d • $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 (UM) Nurse Consultant role is 100% remote and the candidate can live in any state. Normal Working Hours: Monday through Friday 8:30am-5:00pm in the time zone of residence. Shift times may vary occasionally per the need of the department. Rotational late shift 9:30-6CST. No travel is required. 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. The UM Nurse Consultant job duties include (not all encompassing): 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.

Requirements

• Working knowledge of problem solving and decision making skills.
• Working knowledge of medical terminology.
• Working knowledge of digital literacy skills.
• Ability to deal tactfully with customers and community.
• Ability to handle sensitive information ethically and responsibly.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.
• Registered Nurse (RN) required.
• RN with active and unrestricted state licensure in their state of residence
• 2+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience (team is not accepting applicants whose only acute care experience is in behavioral health)

Nice To Haves

• Licensed Clinical Social Worker (LCSW) preferred.
• 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
• BSN preferred.

Responsibilities

• Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
• Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services.
• Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
• Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
• Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
• Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
• Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
• Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making.
• Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.
• 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.
• 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
• Number of Employees: 5,001-10,000 employees