Utilization Management Nurse Consultant Prior Authorization

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Position Summary

Fully remote role.

Requires Monday-Friday: 8:00am-5:00pm in time zone of residence. Weekend/holiday coverage rotation required. Three weeks of training will require 100% participation Monday-Friday, 8am-5pm upon hire.

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. 

• 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

• Demonstrated experience making thorough independent decisions using clinical judgement

Required Qualifications

• 5+ years of clinical experience

• 1+ year(s) of utilization management, concurrent review and/or prior authorization experience

• 5+ years of equipment experience including phone, computer, and clinical documentation systems

• 1+ Microsoft office suited experience

• Must have active, current, and unrestricted license in the state of residence, with multi-state/compact privileges and be willing and able to be licensed in all non-compact states

Preferred Qualifications

• ER and/or ICU clinical experience

• 1+ year(s) Managed Care (MCO) experience

• 1+ year(s) demonstrated experience working in a high volume clinical environment

• Remote work experience

Education

• Associate's nursing degree (RN) minimum required

• Bachelor's degree preferred

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.