Utilization Management Nurse Consultant
4 weeks ago
CVS Health is seeking a skilled Utilization Management Nurse Consultant to join our team. As a key member of our 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 expertise to assess and plan for member care, ensuring alignment with clinical criteria, guidelines, and policies.
- Collaborate with providers and other stakeholders to facilitate care and treatment, promoting quality and effectiveness of healthcare services.
- Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization, consulting with internal and external constituents as needed.
- Develop and maintain relationships with healthcare providers, payers, and other stakeholders to ensure seamless coordination of care.
- Stay up-to-date with industry trends, regulations, and best practices, applying this knowledge to inform clinical decision-making and drive quality improvement initiatives.
- 3+ years of experience as a Registered Nurse, with a strong background in clinical nursing and utilization management.
- Active and unrestricted RN licensure in the state of residence.
- 1+ year of experience in inpatient utilization management, with a focus on clinical decision-making and care coordination.
- Strong analytical and problem-solving skills, with the ability to interpret complex clinical data and develop effective solutions.
- Excellent communication and interpersonal skills, with the ability to build strong relationships with healthcare providers, payers, and other stakeholders.
- Experience working with Medicare and Medicaid populations, with a focus on clinical decision-making and care coordination.
- Knowledge of MCG and other clinical guidelines, with the ability to apply this knowledge to inform clinical decision-making.
- Experience working in managed care, with a focus on clinical decision-making and care coordination.
- UM Certification, with a focus on clinical decision-making and care coordination.
Associates degree required, with a preference for a Bachelor of Science in Nursing (BSN) degree.
Pay RangeThe typical pay range for this role is $29.10 - $62.31 per hour, with a bonus, commission, or short-term incentive program available in addition to the base pay range.
This role 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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