Utilization Management Nurse Consultant – Concurrent Review

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🦀 Maryland – Remote

🦀 Maryland – Remote

💵 $26 - $74 / 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

• Coordinate, document and communicate all aspects of the utilization/benefit management program • Apply critical thinking, clinical knowledge, evidence-based care and medical necessity criteria to utilization decisions • Consult with internal and external constituents on utilization/benefit management • Gather clinical information and apply medical necessity criteria, policies, procedures and clinical judgment to render coverage determinations, recommendations and discharge planning • Evaluate and facilitate appropriate healthcare services and benefits for members, including urgent or emergent interventions such as triage/crisis support • Coordinate and communicate with providers and other parties to facilitate optimal care and treatment • Identify members who may benefit from care management programs and facilitate referrals • Identify opportunities to promote quality and effective healthcare services and benefit utilization

🎯 Requirements

• RN with unrestricted state licensure required • Compact licensure required, with ability to obtain additional licenses as needed • Willingness to obtain additional state licenses • 3+ years of clinical practice experience in an inpatient setting required • Ability to work rotating weekends • AA Nursing required • Managed care/utilization review experience preferred • Acute care/critical care experience preferred • Discharge planning experience preferred • BSN preferred • Work 4 ten-hour shifts in EST, with rotating days off, rotating on-call weekends and holidays

🏖️ Benefits

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

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