Utilization Management Nurse Consultant

CVS Health • Indiana, PA

31d • $32 - $69 • 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.Fully remote with requirement to have an RN license for Illinois.Schedule: Monday through Friday 8A-5PM CST Position Summary- 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

Requirements

• Must have active, current, and unrestricted RN licensure in state of Illinois
• Willingness to obtain additional state licenses upon hire
• 3+ years of clinical practice experience in an inpatient setting as an RN
• Utilization management is a 24/7 operation. Work schedules may include weekends and holidays and evening rotations.

Nice To Haves

• Previous Utilization Management 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

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
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees