Nurse Consultant for Utilization Management

2 weeks ago


Harrisburg, Pennsylvania, United States CVS Health Full time
Position Overview:
This role as a Utilization Management (UM) Nurse Consultant is designed for a fully remote environment, allowing candidates to work from home while providing essential healthcare services.

Work Schedule:
Standard hours are Monday to Friday, from 8:30 AM to 5:00 PM EST, with the requirement to accommodate rotating evening shifts until 9 PM EST based on business needs. Holiday rotations are also part of the role.

Key Responsibilities:
- Leverage clinical expertise to assess and ensure that members receive appropriate care in a timely manner.
- Review clinical documentation to confirm medical necessity and facilitate effective discharge planning.
- Collaborate with healthcare providers and facilities to address the complex needs of members.
- Utilize clinical judgment and established guidelines to make coverage determinations throughout the care continuum.
- Communicate effectively with providers and other stakeholders to support care coordination.
- Identify opportunities for referrals to enhance member engagement with additional services and programs.
- Promote quality and efficiency in healthcare service delivery and benefit utilization.
- Provide expert consultation to internal and external partners regarding utilization management processes.

Required Qualifications:
- Active and unrestricted RN licensure in Pennsylvania, with a minimum of three years of acute care clinical experience, preferably in medical-surgical and ICU settings.
- Proficiency in Microsoft Office Suite and experience navigating multiple computer systems simultaneously.
- Availability to work standard hours with occasional weekend and evening shifts as needed.

Preferred Qualifications:
- At least one year of experience in Utilization Review and Managed Care.
- Strong telephonic communication skills, with an emphasis on time management and organizational abilities.
- An Associate Degree is required, while a BSN is preferred.

Compensation and Benefits:
The typical pay range for this position is competitive and reflects the base hourly rate or annual salary for roles within this job grade. In addition to the base pay, eligible employees can participate in various incentive programs, including bonuses and commissions. CVS Health offers a comprehensive benefits package, including medical, dental, and vision coverage, a 401(k) retirement savings plan, and an Employee Stock Purchase Plan. Additional perks include life insurance, disability benefits, well-being programs, educational assistance, and discounts on CVS products and services. Paid Time Off (PTO) and holidays are also provided in accordance with company policies and state laws.

Diversity and Inclusion:
CVS Health is committed to fostering a diverse and inclusive workplace. We do not discriminate in hiring or employment practices based on any protected characteristic.

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