Utilization Manager 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: 

This Utilization Management (UM) Nurse Consultant role is fully remote and employee can live in any state. 

Normal Working Hours:  

-Monday through Friday 8am-5:00pm in time zone of residence. Shift times may vary occasionally per the need of the department. 

-There is a late shift requirement until 8:00pm EST on a rotating basis. 

-There is a weekend shift requirement (Saturday and Sunday both) per the needs of the team. 

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

• 3+ years of experience as a Registered Nurse
• Must hold active and unrestricted RN licensure in state of residence
• 1+ year(s) of Med/Surg experience
• 1+ year(s) of inpatient utilization experience
• 1+ year(s) of experience with Microsoft Office applications (Outlook, Teams, Excel)
• Most be Willing to work a couple late shift per the team needs of the team
• Most be willing to work weekend shift requirement (Saturday and Sunday both) per the needs of the team. 

• Most have dedicated work area established with high speed internet connection with ethernet hard line connection

  
  Preferred Qualifications
• MCG experience
• Managed care experience
• UM Certification
• MedCompass
  
  Education
• Minimum of an Associate's Degree in Nursing
• 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.