Utilization Management Nurse Consultant

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🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $32 - $68 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

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

• Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program • Review services to assure medical necessity and appropriate benefit utilization • Facilitate safe and efficient discharge planning • Work closely with facilities and providers to meet the complex needs of the member • Utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options for healthcare services/benefits • Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment • Communicate with providers and other parties to facilitate care/treatment • Identify members for referral opportunities and opportunities to promote healthcare service quality effectiveness

🎯 Requirements

• RN with active and unrestricted state licensure in state of residence • 3+ years of clinical experience as an RN preferably in the following areas: Med/Surg, Telemetry, ICU, Long term care, cardiology and oncology • 1+ years’ experience in either Precertification or Utilization Review preferred • 1+ years’ experience Managed Care preferred • Strong telephonic communication skills • 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook) • Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills • Ability to manage multiple priorities, effective organizational and time management skills required

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families