Utilization Management Nurse Consultant

CVS Health

1d•$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 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. 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

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)
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

Nice To Haves

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
Associate Degree in Nursing is minimum required, BSN preferred

Responsibilities

Reviews services to assure medical necessity
Applies clinical expertise to assure appropriate benefit utilization
Facilitates safe and efficient discharge planning
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