Clinical Utilization Management Nurse Consultant
5 days ago
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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