FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Precertification Nurse
CVS Health. Evaluate benefit plan eligibility and facilitate transitions to Aetna programs and plans .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical utilization management, including evaluating benefit plan eligibility, conducting utilization reviews, and coordinating care with healthcare providers. Proficient in navigating healthcare systems and communicating effectively with stakeholders to ensure timely and appropriate care delivery.
Highest-signal resume keywords
Active RN State LicensureUtilization Management ExpertiseClinical Practice ExperienceMicrosoft Office Suite ProficiencyCare Coordination
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewClinical Policy BulletinsEvidence-Based CriteriaMedical Necessity AssessmentCare Plan DevelopmentClaims History ReviewTreatment Plan ReviewDischarge PlanningHealthcare System NavigationMultidisciplinary Team Collaboration
Soft Skills
Organizational SkillsMultitaskingPrioritizationCommunication SkillsFast-Paced Environment Adaptability
Tools & Technologies
Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft Excel
Certifications & Qualifications
Active RN State LicensureAssociate DegreeBSN Preferred
Industry Keywords
Benefit Plan EligibilityClinical ReviewsCare CoordinationUtilization Management StrategiesHealthcare ProvidersClaims ManagementMilliman Care GuidelinesQuality RequirementsElective ProceduresHigh-Cost Claims Monitoring
About the role
Key responsibilities & impact- Evaluate benefit plan eligibility and facilitate transitions to Aetna programs and plans
- Review plan nuances, Institute of Quality requirements, benefit exclusions, second-opinion requirements, and claims history
- Conduct utilization reviews and assessments using evidence-based criteria, clinical policy bulletins, Milliman Care Guidelines, and clinical knowledge
- Review medical records, treatment plans, and documentation to determine medical necessity and appropriateness of elective procedures
- Communicate determinations and current case status to providers and members
- Guide members through the healthcare system and assess, plan, implement, and coordinate care telephonically
- Collaborate with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans
- Prioritize clinical reviews, escalations, dates of service, and case types to maintain timeliness guidelines
- Monitor high-cost claims, level of care, length of stay, and discharge planning needs
- Recommend referrals to clinical resources for healthcare-system navigation
- Provide utilization and benefit-management expertise to internal and external constituents
- Communicate with stakeholders to facilitate care coordination and address utilization-management inquiries
- Contribute to utilization-management strategies, policies, and procedures
- Present cases at medical director rounds or care calls and consult with supervisors to overcome barriers
Requirements
What you’ll need- Active, current and unrestricted compact RN state licensure
- Must reside within 45 miles of office locations in New Albany, OH, Chandler, AZ, or High Point, NC
- 3+ years of clinical practice experience
- Ability to work Monday through Friday, 8:00 AM to 4:30 PM in the local time zone, with evening rotation about twice a month until 8:00 PM EST
- Ability to work from home with occasional on-site work requirements
- 2+ years of experience using Microsoft Office Suite applications, including Teams, Outlook, Word, and Excel
- Ability to organize, multitask, prioritize, and work in a fast-paced environment
- Computer skills
- Associate degree required
- BSN preferred
Benefits
Comp & perks- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility