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

Normal Working Hours:

• 8:30am-5:00pm in time zone of residence Saturday and Sunday bi monthly
• Holiday rotation per the need of the department (typically 1 holiday per year).

There is no travel expected with this position.
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 be an RN with active current and unrestricted RN state licensure in state of residence
• 2+ years of clinical experience as an RN (all clinical areas considered: Home Health, Med/Surg, Telemetry, ICU, NICU, Long term care, orthopedics, and more)
• Must be willing to work 8:30am-5:00pm in time zone of residence. Shift times may vary occasionally per the need of the department
• Must be willing to work late shift requirement until 9:00pm EST approximately 3 times per year
• Must be willing to work weekend shift requirement per the needs of the team.
• Must be willing to work Holiday rotation per the need of the department (typically 1 holiday per year)

PREFERRED QUALIFICATIONS:

• 1+ years’ experience Utilization Review experience
• 1+ years’ experience Managed Care
• Strong telephonic communication skills
• 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
• Experience with computers toggling between screens while using a keyboard and speaking to customers.
• Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills
• Ability to manage multiple priorities, effective organizational and time management skills required
• Ability to use a computer station and sit for extended periods of time

EDUCATION:

Associates Degree required
BSN preferred

• 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