Utilization Management Clinical Consultant

Job not on LinkedIn

🔥 0 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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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

• Coordinate, document, and communicate all aspects of the utilization/benefit management program • Apply critical thinking, evidence-based care, medical necessity criteria, policies, procedures, and clinical judgment to utilization decisions • Consult with internal and external constituents on utilization/benefit management coordination and administration • Gather clinical information and render coverage determinations, recommendations, and discharge planning across the continuum of care • Evaluate and facilitate appropriate healthcare services and benefits for members • Coordinate and communicate with providers and other parties to facilitate optimal care and treatment • Identify members who may benefit from care management or post-discharge programs and facilitate referrals • Identify opportunities to promote quality and effective healthcare services and benefit utilization • Handle cases in a Skilled Nursing Facility setting • Conduct retrospective reviews and analyze claims after assessment

🎯 Requirements

• Active, unrestricted Arizona RN license or a compact license that includes Arizona • 3+ years clinical practice experience in a hospital setting, SNF, home health, ambulatory care, or similar alternative care setting • Associate's degree in nursing (RN) required • Clinical experience in ER, ICU, or Critical Care preferred • Managed Care/Utilization Management experience • Ability to make thorough independent decisions using clinical judgement • Proficient use of equipment including computer and phone, and clinical documentation systems • Experience with Claims Review processes • Dedicated workspace free of interruptions • Separate dependent care arrangements during work hours; continuous care responsibilities during shift times are not permitted • Ability to work Monday–Friday, 8:30am–5:00pm AZT

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility