Utilization Management Nurse Consultant

4 weeks ago


Renton, Washington, United States CVS Health Full time
Job Summary

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.
Requirements
  • 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.
Preferred Qualifications
  • 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.
Education

Associates degree required, with a preference for a Bachelor of Science in Nursing (BSN) degree.

Pay Range

The 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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