Utilization Management Nurse 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

• Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services and benefits for members • Gather clinical information and apply clinical criteria, guidelines, policies, procedures and clinical judgment to render coverage determinations or recommendations • Communicate with providers and other parties to facilitate care and treatment • Identify members for referral opportunities involving other products, services and programs • Identify opportunities to promote healthcare service quality and effective benefit utilization • Consult and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management • Work in a 24/7 operation with schedules including weekends, holidays and evening hours • Navigate multiple systems, applications and monitors while maintaining productivity and quality expectations • Troubleshoot common technical issues and contact IT for unresolved issues

🎯 Requirements

• 2+ years of experience as a Registered Nurse in an adult acute care or critical care setting • Active, current and unrestricted RN licensure in the state of residence • 2+ years of clinical experience in a med-surg or specialty area • Managed Care experience preferred, especially Utilization Management • Preference for candidates residing in EST zones • Associate's Degree required; BSN preferred • Ability to work weekends, holidays and evening hours in a 24/7 operation • Effective verbal and written communication skills • Proficiency navigating multiple computer systems and keyboarding • Ability to perform close inspection of handwritten and computer-generated documents and PC monitor • Ability to multitask, prioritize and adapt to a fast-paced changing environment • Direct/hardwired internet connection to a modem/router within 7 feet of the computer • Minimum internet speed of 25 Mbps download and 3 Mbps upload • WiFi and satellite internet are not permitted • Quiet, secure, private and HIPAA-compliant designated home workspace free from distractions • Must work within the state and city where currently living • Must provide own workspace furniture • Ability to use multiple monitors and applications simultaneously • Ability to use email, calendar invites, Teams messaging and virtual meetings • Experience with Microsoft Office 365 applications or similar Google Workspace applications • Ability to log in to secure systems such as VPN and EHR portals • Ability to maintain strong passwords and recognize suspicious emails or links • Ability to resolve common technical issues independently • Openness to learning new skills as the workplace evolves

🏖️ 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 • Company-provided equipment (keyboard, monitor, computer, headset, etc.)