Utilization Management Nurse Consultant

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

100% remote position from anywhere in the U.S.
Schedule is Monday-Friday 11:30AM-8:00PM EST. MUST have the ability to work the occasional on-call rotational coverage on weekends and some rotational on-call holiday coverage (URAC and Client Requirements).
Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for treatment and services both inpatient and outpatient requiring precertification. The majority of the time is spent at a desk and on the telephone collecting & reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Position requires proficiency with computer skills which includes navigating multiple systems. Sedentary work involves periods of sitting, talking, listening and computer use

REQUIRED QUALIFICATIONS

• 1+ year varied Utilization Management experience within an inpatient/Outpatient setting, concurrent review or prior authorization.
• 5+ years of variety clinical experience required including acute care, home health, or long term care.
• 5+ years Demonstrated to make thorough independent decisions using clinical judgement
• 5+ Years Proficient use of equipment experience including phone, computer, etc and clinical documentation systems
• Required to attend the first 3 weeks training with 100% participation during 8:30am-5pm Monday-Friday.
• 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 state

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’s degree in nursing (RN) required, BSN preferred

Please refer the Job description for details