Utilization Management Nurse Consultant

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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

100% remote position from anywhere in the U.S.

Work hours: 11:30am-8:00pm EST, Monday-Friday.

Weekend/holiday coverage will occasionally be required.

100% attendance is required during the first 3 weeks of training / 8:30am-5pm EST, Monday-Friday.

Work in clinical telephone queue for 2 to 4 hours a day working with providers to secure additional information for prior authorization review. This candidate will utilize 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 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. WFH and hybrid Colleagues must manage dependent care and other personal responsibilities in a way that allows them to successfully meet job responsibilities while working from their virtual work location. Dependent care performed during work hours is generally not permissible, as it creates the potential for unnecessary interruptions and distractions from work

Required Qualifications

• 5 years of a variety clinical experience required including acute care, home health, or long-term care.
• 5 years demonstrated ability to make thorough, independent decisions using clinical judgement.
• A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have …