Utilization Management Nurse Consultant

Job not on LinkedIn

🔥 5 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $26 - $68 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 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

• Conduct utilization reviews and clinical assessments to evaluate medical necessity, appropriateness, and efficiency of healthcare services • Apply evidence-based criteria and clinical expertise to benefit and utilization management decisions • Review medical records, treatment plans, and supporting documentation for compliance • Develop, coordinate, and support care plans with providers, multidisciplinary teams, and payers • Prepare, audit, and manage approval and denial letters • Promote utilization management practices through consultation, education, and collaboration • Support care coordination to improve member outcomes and access to healthcare services • Communicate with providers, members, and internal teams regarding utilization management decisions • Maintain complete, accurate, and timely documentation • Provide guidance and coaching to nursing staff and healthcare professionals • Contribute to utilization management policies, procedures, and quality improvement initiatives • Promote quality, effectiveness, and efficiency of healthcare services across the continuum of care

🎯 Requirements

• Active Registered Nurse (RN) license • 3-5 years of relevant clinical, case management, utilization management, or healthcare experience • Knowledge of medical terminology and healthcare delivery systems • Strong problem-solving and critical-thinking skills • Effective decision-making abilities with demonstrated clinical judgment • Proficiency with technology and digital tools used in healthcare environments • Ability to analyze costs and benefits of alternative approaches and recommend appropriate solutions • Strong interpersonal and communication skills • Ability to maintain confidentiality and handle sensitive information ethically and responsibly • Ability to work effectively within diverse clinical and cultural environments • Must be available to work Thursday-Sunday, 9:00 AM to 8:00 PM Eastern Time • Experience in utilization management, care management, managed care, or health plan operations preferred • Knowledge of regulatory, accreditation, and quality standards related to utilization management preferred • Experience reviewing medical necessity criteria and healthcare benefits preferred • Bachelor's degree in Nursing, Healthcare Administration, or a related healthcare field preferred • Equivalent specialized training, certification, or relevant professional experience may be considered in lieu of a degree

🏖️ 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 eligibility