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.

Fully remote with requirement to work the following schedule:

Monday-Friday 8:00am-4:30pm EST.

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.

Required Qualifications

- Must have active, current, and unrestricted RN licensure in state of residence

- Must be available to work Monday through Friday 8:00am - 4:30pm EST

- Must be willing to work weekend rotation, once per month

- Holiday rotation per the need of the department (typically 1 holiday per year)

- 3+ years of clinical RN experience

-1+ years of experience using  Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications

-1+ years’ experience Utilization Review experience

-1+ years’ experience Managed Care

- Strong communication skills

- Ability to manage multiple priorities, effective organizational and time management skills required

- Experience in healthcare utilization management, critical care, emergency department, or case management

Education

Associate degree 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.