Utilization Management Nurse Consultant – Medical Review

Job not on LinkedIn

November 26

🏈 Ohio – Remote

Although this job is listed in Ohio, this company may be open to hiring remote in other states.

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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CVS Health

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Healthcare Insurance • Retail • Wellness

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.

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

📋 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 • Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements

🎯 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

• Affordable medical plan options • 401(k) plan (including matching company contributions) • 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