Utilization Management Nurse Consultant – MST/PST Zone

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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 services for medical necessity and appropriate benefit use • Facilitate efficient discharge planning • Collaborate with providers and facilities to support members with complex needs • Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits • Collect and evaluate clinical information using clinical criteria, guidelines, policies, and judgment to make coverage determinations • Communicate with providers and external partners to coordinate care and treatment plans • Identify referrals to additional programs, services, or care solutions • Promote quality care delivery and effective benefit utilization • Serve as a resource to internal and external stakeholders on UM processes and clinical considerations • Coordinate, document, and communicate utilization and benefit management activities while meeting state and federal requirements and turnaround times

🎯 Requirements

• Active, unrestricted RN license • 2+ years of acute hospital clinical experience • Strong preference for medical-surgical, ICU, behavioral health, or another specialty area • Strong clinical assessment and decision-making abilities • Excellent organizational skills and ability to manage multiple priorities • Ability to work independently and communicate effectively by 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 sound judgment and ability to collaborate with diverse teams • Associate Degree in Nursing (ADN) required • Bachelor of Science in Nursing (BSN) preferred • Availability for Monday–Friday, 8:00 AM–5:00 PM CST • Weekends (12 per year) and holidays (1 minor and 1 major per year) required • One 1:00 PM–7:00 PM shift per month, with day selection

🏖️ 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