Utilization Management Nurse Consultant

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
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.

  American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

  Work in clinical telephone queue for 4 to 6 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 the ability to be licensed in all noncompact states.
  • 1 year of varied UM (utilization management) experience within an inpatient/outpatient setting, concurrent review or prior authorization.
  • Required to use a residential broadband service with internet speeds of at least 25 mbps/3mbps in order to ensure sufficient speed to adequately perform work duties. Some candidates may be eligible for partial reimbursement of the cost of residential broadband service.
     

  
  Preferred Qualifications

  • 1+ years Managed Care (MCO) preferred.
  • 1+ years demonstrated experience working in a high-volume clinical call center environment.
  • Remote work experience.
     

  
  
  Education

  Associate degree in nursing RN required.

  BSN 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.