Utilization Management Nurse Consultant

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Fully remote with requirement to work the following schedule:

Monday-Friday 8:00am-4:30pm EST.

Position Summary    

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 have active, current, and unrestricted RN licensure in state of residence

- Must be available to work Monday through Friday 8:00am - 4:30pm EST

- Must be willing to work weekend rotation, approximately every 6 weeks

- Holiday rotation per the need of the department (typically 1 holiday per year)

- 3+ years of clinical RN experience

-1+ years of experience using  Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications

-1+ years’ experience Utilization Review experience

-1+ years’ experience Managed Care

- Strong communication skills

- Ability to manage multiple priorities, effective organizational and time management skills required

- Experience in healthcare utilization management, critical care, emergency department, or case management

Education

Associate degree required

BSN preferred

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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