As a Utilization 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. Looking for someone who is high energy and motivated team environment and is detail oriented and highly organized.

The UM Nurse Consultant 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 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.
• There are standard productivity and quality expectations.
• Work requires the ability to perform close inspection of handwritten and computer generated documents.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written

Required Qualifications
- Must have an active, current and unrestricted RN license
- 2+ years of recent acute hospital clinical experience as an RN (recent defined as in the past 10 years).

- Must be willing and able to work Monday through Friday 8:00am-6:00pm in the time zone of residence; Team is open to candidates in PST and/or MST time zones to provide increased daily coverage until 6:30pm EST (10:00am-6:30pm EST).

- Saturday weekend rotation required

- Must be willing and able to travel up to 10% to complete audits as needed

- 1 + years of experience with all types of Microsoft Office including PowerPoint, Excel, and Word

Preferred Qualifications

- Utilization Review experience

- Managed Care background

- Strong telephonic communication skills

Education

Associates Degree required

BSN preferred

Pay Range

The typical pay range for this role is:

$32.01 - $68.55

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

We anticipate the application window for this opening will close on: 11/25/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.