Utilization Management Nurse Consultant

Job not on LinkedIn

🔥 12 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Review clinical documentation and apply medical necessity criteria, policies, and clinical guidelines to make coverage determinations and recommendations • Coordinate and communicate utilization and benefit management activities across the continuum of care • Collaborate with providers, healthcare teams, and internal stakeholders on treatment plans, discharge planning, and care transitions • Apply critical thinking and clinical judgment to support evidence-based care and appropriate resource utilization • Identify members who may benefit from care management programs and facilitate referrals • Support urgent and emergent member needs, including triage and crisis intervention when necessary • Serve as a clinical resource and consultant for internal and external partners regarding utilization management processes and decisions • Promote quality improvement initiatives and identify opportunities to enhance healthcare outcomes and benefit utilization

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license in the state of Florida • Minimum of 3 years of recent inpatient clinical nursing experience • Ability and willingness to obtain additional state nursing licenses as needed (company-sponsored) • Must permanently reside in Florida • Strong clinical assessment, documentation, communication, and critical-thinking skills • Associate Degree in Nursing (ADN) required • Previous Utilization Management (UM) experience preferred • Managed Care experience preferred • Discharge planning and care coordination experience preferred • Experience applying medical necessity guidelines and utilization review criteria preferred • Schedules may include evenings, weekends, and holidays

🏖️ 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

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