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Utilization Management Nurse Consultant
CVS Health. Review clinical cases and make coverage determinations using evidence-based guidelines .
About the role
Key responsibilities & impact- Review clinical cases and make coverage determinations using evidence-based guidelines
- Collaborate with home care providers, attending MDs and care teams to coordinate transitions from hospital and/or post-acute settings to home care
- Apply clinical judgment to support utilization and benefit management decisions
- Identify opportunities to improve care quality and member outcomes
- Serve as a clinical resource across internal and external stakeholders
Requirements
What you’ll need- Active, unrestricted RN license in the state of residence
- 2+ years of RN experience, including 1+ year in Med/Surg
- Strong clinical assessment and decision-making skills
- Experience with Microsoft Office (Outlook, Teams, Excel)
- Ability to work Monday–Friday, 9:00 AM–6:00 PM in your time zone
- Work schedules will include holidays and evening hours because Utilization Management is a 24/7 operation
- Associate Degree in Nursing
- Utilization Management or Prior Authorization experience preferred
- Managed care background preferred
- Home health experience preferred
- 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