Utilization Management Nurse Consultant

CVS Health

1d • $26 - $69

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. The UM Nurse Consultant job duties include (not all encompassing): - Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. - Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. - Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members - Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care - Communicates with providers and other parties to facilitate care/treatment - Identifies members for referral opportunities to integrate with other products, services and/or programs - Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization - Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Requirements

• Must be an RN with active, current and unrestricted RN state licensure in state of residence
• 3+ years of clinical experience as an RN (all clinical areas considered: Home Health, Med/Surg, Telemetry, ICU, NICU, Long term care, orthopedics, and more)
• 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
• Must be willing to work Monday through Friday 8:00am-4:30pm. Shift times may vary occasionally per the need of the department and business needs.
• Must be willing and able to work weekend and/or holiday shift requirement per the needs of the team and business needs.

Nice To Haves

• 1+ years’ experience Utilization Review experience
• 1+ years’ experience Managed Care
• Strong telephonic communication skills
• Experience with computers toggling between screens while using a keyboard and speaking to customers.
• Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills
• Ability to manage multiple priorities, effective organizational and time management skills ]
• Ability to use a computer station and sit for extended periods of time

Responsibilities

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care
• Communicates with providers and other parties to facilitate care/treatment
• Identifies members for referral opportunities to integrate with other products, services and/or programs
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree