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Clinical Utilization Management Specialist

1 month ago

Atlanta, Georgia, United States CVS Health Full time
Job Summary

CVS Health is seeking a skilled Clinical Utilization Management Specialist to join our team. As a key member of our Utilization Management team, you will play a critical role in assessing, planning, implementing, coordinating, monitoring, and evaluating options to facilitate appropriate healthcare services and benefits for our members.

Key Responsibilities:

  • Utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.
  • Gather clinical information and apply the appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations and recommendations along the continuum of care.
  • Communicate with providers and other parties to facilitate care and treatment.
  • Identify members for referral opportunities to integrate with other products, services, and programs.
  • Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization.
  • Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization and benefit management function.

Requirements:

  • 3+ years of experience as a Registered Nurse.
  • Must possess 1+ years of clinical experience in an acute or post-acute setting.
  • Must have active, current, and unrestricted RN licensure in the state of residence.
  • Must be able to obtain a CA nursing license within 6 months of hire (paid for by the company).
  • Must be willing and able to work Monday through Friday, 8:00am to 5:00pm EST.

Preferred Qualifications:

  • 3+ years of clinical experience.
  • Managed Care experience.

Benefits:

  • 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.
  • An Employee Stock Purchase Plan is also available for eligible employees.
  • The Company provides a fully-paid term life insurance plan to eligible employees.
  • Short-term and long-term disability benefits.
  • Numerous well-being programs.
  • Education assistance.
  • Free development courses.
  • A CVS store discount.
  • Discount programs with participating partners.

Time Off:

  • Company employees enjoy Paid Time Off (PTO) or vacation pay.
  • Paid holidays throughout the calendar year.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.