UM Nurse Consultant (RN in KY)

at  CVS Health

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

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization and benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for medical conditions based upon program focus.
• Consults and lends Utilization Management expertise to internal and external constituents in the coordination and administration of the utilization and benefit management functions to produce optimal results.
• Gathers clinical information and utilizes best practices to apply the appropriate medical criteria, along with relevant guidelines, policies, procedures, and clinical judgment to effectively render coverage determination/recommendation along the continuum of care.
• Acts as a top-level specialist utilizing clinical experience and consultant skills in a collaborative process to assess, plan, implement, coordinate, monitor, evaluate and facilitate appropriate healthcare services and benefits for members, including urgent or emergent interventions.
• Coordinates and proactively communicates with key medical providers and other key third parties to facilitate the optimal care and treatment for all customers, based on their specific medical needs and expectations.
• Identifies members who may benefit from comprehensive care management programs, facilitating referrals based on specific customer needs and medical requirements.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
• Coaches and trains junior colleagues in techniques, processes, and responsibilities.

REQUIRED QUALIFICATIONS

• Must have active, current, and unrestricted RN licensure in state of KY

• Must be available to work M-F; 8am - 5pm EST

• After training is completed, will be on call for 1 weekend every 3 months (will be paid a differential for these hours)

• 3+ years of clinical practice experience in an inpatient setting as an RN

PREFERRED QUALIFICATIONS

• Managed care experience
• Discharge planning experience
• Utilization Management experience

EDUCATION

• Associates degree or Nursing Diploma Required
• Bachelors Degree Preferred

Please refer the Job description for details