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Clinical Utilization Management Specialist
2 months ago
CVS Health is seeking a skilled Clinical Utilization Management Specialist to join our team. As a key member of our healthcare team, you will play a critical role in ensuring that our members receive the most appropriate care at the right time and in the right setting.
Key Responsibilities- Coordinate and Document Utilization Management Activities: Utilize clinical expertise to coordinate, document, and communicate all aspects of the utilization/benefit management program.
- Review and Assess Medical Necessity: Review services to ensure medical necessity and apply clinical expertise to ensure appropriate benefit utilization.
- Facilitate Safe and Efficient Discharge Planning: Work closely with facilities and providers to meet the complex needs of our members.
- Communicate with Providers and Other Parties: Communicate with providers and other parties to facilitate care and treatment.
- Identify Opportunities for Quality Improvement: Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization.
- Active RN Licensure in Pennsylvania: Must have an active, current, and unrestricted RN licensure in the state of Pennsylvania.
- Acute Hospital Clinical Experience: 3+ years of acute hospital clinical experience as an RN, with a preference for medical-surgical and ICU experience.
- Microsoft Office Suite Experience: 3+ years' experience with Microsoft Office Suite, with the ability to provide examples of navigating multiple computer systems and keyboarding at the same time.
- Availability to Work Rotating Shifts: Must be able to work Monday through Friday 8:30am - 5pm EST, with occasional weekend rotation per business needs, and evening rotation until 9pm EST depending on business needs.
- Utilization Review Experience: 1+ years' experience in utilization review.
- Managed Care Experience: 1+ years' experience in managed care.
- Strong Telephonic Communication Skills: Strong telephonic communication skills.
- Time-Efficient and Highly Organized: Time-efficient and highly organized.
