Utilization Management Nurse Consultant

Job not on LinkedIn

🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

💼 Consultant

👻 Ghost score 0%

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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

• Coordinate, document and communicate all aspects of the utilization/benefit management program • Ensure members receive appropriate care at the appropriate time and location while adhering to federal and state regulated turnaround times • Review written clinical records and services to assure medical necessity • Apply clinical expertise, criteria, guidelines, policies, procedures and clinical judgment to determine or recommend coverage • Facilitate safe and efficient discharge planning • Collaborate with facilities, providers and other parties to meet complex member needs and facilitate care • Assess, plan, implement, coordinate, monitor and evaluate healthcare service and benefit options • Identify members for referral opportunities to other products, services and programs • Identify opportunities to promote healthcare service quality and effective benefit utilization • Consult with internal and external constituents on utilization/benefit management coordination and administration • Minimal travel, potentially up to 10%, for clinical audits

🎯 Requirements

• Active, current and unrestricted RN license in state of residence • 2+ years of recent acute hospital clinical experience as an RN, defined as within the past 10 years • 1+ years of experience with Microsoft Office, including PowerPoint, Excel, and Word • Willingness and ability to work Monday through Friday, 8:00am–4:30pm in the time zone of residence • Willingness and ability to work weekend and holiday rotation per department needs • Associate Degree in Nursing required • Utilization Review experience preferred • Managed Care background preferred • Strong telephonic communication skills preferred • Bachelor's in Science & Nursing preferred

🏖️ 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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