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.
Primary Job Duties & Responsibilities
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- Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
- Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services.
- Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
- Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
- Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
- Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
- Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
- Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making.
- Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.
- Active and unrestricted RN license in the state of residence
- 3+ years clinical experience
- Working hours are Monday-Friday, 8:00am-4:30pm EST with rotating Saturday
- Utilization review experience
- Medical record review experience
- Experience with Milliman
- Experience using computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)
- Associate degree in Nursing required
- BSN preferred
The typical pay range for this role is:
$26.01 - $56.14
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: 11/26/2024
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.