Utilization Management Nurse Consultant – Medical Review

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🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $26 - $56 / 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

• Implement, coordinate, monitor and evaluate medical review cases • Apply clinical criteria, guidelines, plan language and policy specifics to render medical determinations • Apply critical thinking, evidence-based clinical criteria and clinical practice guidelines • Authorize procedures/services or initiate Medical Director referrals as needed • Assist management with training, mentoring and providing feedback to new nurse reviewers, business partners and vendors • Cross-train to perform reviews of multiple case types • Recommend, test and implement process, audit and technology improvements • Work independently to meet quality and metric expectations • Collaborate with providers to help members receive timely, medically necessary care

🎯 Requirements

• Active, unrestricted RN license in state of residence with multistate/compact licensure privileges • Ability to obtain licensure in non-compact states as needed • Minimum 3 years of clinical experience • 5 years demonstrated ability to make thorough independent decisions using clinical judgment • 5 years of proficient equipment use, including phone and computer, and clinical documentation systems • 1+ year of Utilization Review Management and/or Medical Management experience • Mandatory 3-week training with 100% participation, Monday–Friday, 8:30am–5:00pm EST • Associate's degree in nursing (RN) required • BSN preferred • Experience interpreting plan language, policies and benefits preferred • MCG Milliman, CPB or other criteria guideline application experience preferred • Dedicated workspace free of interruptions • Dependents must have separate care arrangements during work hours

🏖️ 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 • Dedicated remote workspace