Utilization Management Nurse Consultant – EST/CST Zone

Job not on LinkedIn

🔥 1 hour ago

🐊 Florida, Texas – Remote

🐊 Florida – Remote 🤠 Texas – Remote

💵 $29 - $62 / 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 clinical background to coordinate, document, and communicate all aspects of utilization and benefit management process. • Ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times. • Involves reviewing clinical documentation, collaborating with providers, and supporting high-quality, cost-effective care. • Reviewing services for medical necessity and appropriate benefit use. • Facilitating efficient discharge planning. • Collaborating with providers and facilities to support members with complex needs. • Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits. • Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations. • Communicating with providers and external partners to coordinate care and treatment plans. • Identifying opportunities for referrals to additional programs, services, or care solutions. • Recognizing opportunities to promote quality care delivery and effective benefit utilization. • Serving 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. • 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 (preferred)

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility