Nurse Consultant Utilization Management

1 week ago


Jefferson City, Missouri, United States CVS Health Full time
Job Summary

CVS Health is seeking a skilled Nurse Consultant Utilization Management to join our team. As a key member of our healthcare services team, you will play a critical role in ensuring that our members receive the highest quality care while minimizing unnecessary healthcare costs.

Key Responsibilities
  • Review and evaluate clinical information and documentation related to outpatient therapy services
  • Interpret data obtained from clinical records or systems and apply clinical decision-making to determine appropriate clinical criteria and policies
  • Coordinate clinical resolution with clinician/MD support as required
  • Act as a resource for customer service and claims processing areas
  • Utilize clinical experience and skills to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members
  • Communicate with providers and other parties to facilitate care/treatment
  • Identify members for referral opportunities to integrate with other products, services, and/or 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/benefit management function
Requirements
  • 3+ years of experience as a Registered Nurse
  • Active current and unrestricted RN licensure in state of residence
  • 1+ years of clinical experience in acute or post-acute setting
  • Ability to work in a 24/7 operation, including weekends and holidays, and evening rotations
Preferred Qualifications
  • Managed care experience
  • Discharge planning experience
  • Utilization Management experience
What We Offer

CVS Health offers a competitive salary range of $26.01 - $56.14, as well as a comprehensive benefits package, including medical, dental, and vision benefits, 401(k) retirement savings plan, and employee stock purchase plan. We also offer a fully-paid term life insurance plan, short-term and long-term disability benefits, and numerous well-being programs.


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