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Clinical Utilization Management Nurse Specialist
2 months ago
About CVS Health
At CVS Health, we are united by a common mission: to bring compassion to every aspect of health care. Our commitment is to provide personalized, accessible, and affordable health solutions in a rapidly evolving landscape.
Position Overview
This role as a Utilization Management Nurse Consultant is entirely remote, allowing flexibility for candidates across the nation. There is no requirement for travel.
Key Responsibilities
As a Utilization Management Nurse Consultant, your clinical expertise will be essential in overseeing, documenting, and communicating all facets of the utilization and benefit management program. Your primary goal will be to ensure that members receive the right care at the right time and in the right setting, all while complying with established federal and state turnaround times.
- Evaluate services to confirm medical necessity, leveraging clinical knowledge to ensure optimal benefit utilization, and facilitate safe discharge planning while collaborating with healthcare facilities and providers to address the complex needs of members.
- Employ clinical skills to coordinate, document, and communicate all elements of the utilization and benefit management program.
- Utilize clinical experience in a collaborative manner to assess, plan, implement, coordinate, monitor, and evaluate options that promote appropriate healthcare services and benefits for members.
- Collect clinical information and apply relevant clinical criteria, guidelines, policies, and clinical judgment to make coverage determinations and recommendations throughout the care continuum.
- Engage with providers and other stakeholders to facilitate care and treatment.
- Identify members for referral opportunities to integrate with additional products, services, and programs.
- Spot opportunities to enhance the quality and effectiveness of healthcare services and benefit utilization.
- Provide consultation and expertise to internal and external stakeholders regarding the coordination and administration of the utilization and benefit management functions.
Required Qualifications
- Active, unrestricted RN licensure in your state of residence.
- A minimum of 3 years of acute hospital clinical experience as an RN, with a preference for medical-surgical and ICU backgrounds (candidates with only behavioral health experience will not be considered).
Preferred Qualifications
- At least 1 year of experience in Utilization Review.
- A minimum of 1 year of experience in Managed Care.
- Strong telephonic communication skills.
- Proficiency in Microsoft Office Suite.
Work Schedule
- Availability to work Monday through Thursday from 8:00 AM to 4:30 PM and Friday from 8:30 AM to 5:00 PM, with occasional weekend and holiday hours.
Compensation and Benefits
The typical pay range for this position is $56.14 per hour. This range represents the base hourly rate or base annual full-time salary for all positions within this job grade. Actual salary offers will depend on various factors, including experience, education, and geographic location. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.
CVS Health offers a comprehensive benefits package, including medical, dental, and vision coverage, a 401(k) retirement savings plan, an Employee Stock Purchase Plan, fully-paid term life insurance, and both short-term and long-term disability benefits. Employees also have access to numerous well-being programs, education assistance, free development courses, and discounts.
We are an equal opportunity and affirmative action employer, committed to creating a diverse and inclusive workplace.
