Utilization Management Nurse Consultant – UM

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🔥 3 hours ago

🌪️ Kansas, Mississippi, +2 more states – Remote

🌪️ Kansas – Remote 🎸 Mississippi – Remote 🤠 Texas – Remote 🧀 Wisconsin – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

💼 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

• Use your clinical background to coordinate, document, and communicate all aspects of the utilization and benefit management process • Ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times • Review clinical documentation, collaborating with providers, and supporting high-quality, cost‑effective care • Reviewing services for medical necessity and appropriate benefit use • Facilitate efficient discharge planning • Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits • Collect and evaluate clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations • Communicate with providers and external partners to coordinate care and treatment plans • Identify opportunities for referrals to additional programs, services, or care solutions • Promote quality care delivery and effective benefit utilization • Serve as a resource to internal and external stakeholders regarding UM processes and clinical considerations

🎯 Requirements

• Active, unrestricted RN license • 2+ years of acute hospital clinical experience (strong preference for medical‑surgical, ICU, behavioral health or other specialty area) • Strong clinical assessment and decision‑making abilities • Excellent organizational skills with the ability to manage multiple priorities • Ability to work independently and communicate effectively via phone • Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls • Preferred: 1+ year of Utilization Review experience • Preferred: 1+ year of Managed Care experience • Preferred: Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) • Preferred: Strong telephonic communication skills • Preferred: Demonstrated ability to exercise sound judgment and collaborate with diverse teams

🏖️ Benefits

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