Utilization Management Nurse Consultant – Medical Review

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🕒 July 22

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. • Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. • Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. • Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. • Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. • Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. • Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. • Must be able to work independently without personal distractions to meet quality and metric expectations.

🎯 Requirements

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. • Ability to obtain licensure in non-compact states as needed. • Minimum 3 years of clinical experience. • 5 years demonstrated to make thorough independent decisions using clinical judgement. • 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. • 1+ Year of Utilization Review Management and/or Medical Management experience. • Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs