Clinical Utilization Management Nurse Consultant

5 days ago


Cary, North Carolina, United States CVS Health Full time

Job Summary

This Clinical Utilization Management Nurse Consultant role is a fully remote position that can be based in any state. As a key member of the CVS Health team, you will play a critical role in assessing, planning, implementing, coordinating, monitoring, and evaluating options to facilitate appropriate healthcare services and benefits for 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 determination/recommendation 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/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 an RN.
  • 1+ years of inpatient hospital experience.
  • Must have active, current, and unrestricted RN licensure in the state of residence.
  • Able to work in multiple IT platforms/systems.
  • Must be willing and able to work Monday through Friday, 9:30am to 6:00pm in the EST zone.
  • Must be willing and able to work weekends (1 to 2 per month).
  • Must be willing and able to work holiday rotation (1 to 2 per year).
  • 1+ year(s) of Med/Surg experience.
  • 1+ year(s) of experience with Microsoft Office applications (Outlook, Teams, Excel).

Preferred Qualifications

  • Experience with Medicare/Medicaid populations.
  • MCG experience.
  • Managed care experience.
  • UM Certification.
  • MedCompass.
  • 1+ year(s) of inpatient utilization experience.

Education

  • Associates Degree required.
  • BSN preferred.

Compensation

The typical pay range for this role is $65.66 per hour. 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.



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