Utilization Management Nurse Consultant

CVS Health•Work At Home-Pennsylvania, TX

8d•$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 Fully remote role. Tuesday–Saturday. Hours are 10:00 a.m.–6:30 p.m. Tuesday through Friday. Saturday hours may be either 8:00 a.m.–4:30 p.m. or 10:00 a.m.–6:30 p.m. ET. Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare Integrated/dually eligible member populations. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.

Requirements

Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
1+ years of behavioral health utilization review/utilization management experience required.
3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health-focused work since the inpatient setting experience.

Nice To Haves

Experience working with Medicare, Medicaid, or dually eligible populations.
Experience working with geriatric or chronically mentally ill populations.
Experience supporting high-risk member populations.
Strong computer proficiency, including navigating multiple systems and accurate keyboarding.

Responsibilities

Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.
Coordinate, monitor, and assess healthcare service options to help ensure Medicare Integrated/dually eligible members receive appropriate, cost-effective care.
Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.
Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.
Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.
Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.
Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.
Perform responsibilities while working primarily at a computer, including extended periods of phone communication.