Utilization Management Nurse Consultant
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 SummaryThis Registered Nurse Utilization Management position is an exciting opportunity to join a growing Aetna Custom Care Team for a dedicated customer. You'll have the opportunity to work in an exciting, fast pace atmosphere and administer a high touch integrated model, utilizing your clinical experience to review a combination of precertification and current current review stays. Primary Job Duties & ResponsibilitiesDrives 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.Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.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.
Requirements
- Registered Nurse (RN), preferably in a compact state
- 3-5 years Prior Relevant Work Experience
- 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.
Nice To Haves
- Functional experience with Microsoft products such as outlook, teams, word and excel.
- Bachelor's degree preferred/specialized training/relevant professional qualification.
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.
- Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
- 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.
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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Ambulatory Health Care Services
Number of Employees
5,001-10,000 employees
