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Utilization Management Nurse Consultant
CVS Health. Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members .
About the role
Key responsibilities & impact- Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members
- Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations
- Communicate with providers and other parties to facilitate care and treatment
- Identify members for referral opportunities involving other products, services, or programs
- Identify opportunities to promote healthcare service quality and effective benefit utilization
- Consult and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
- Work within a 24/7 utilization management operation
Requirements
What you’ll need- 3-5 years of Med/Surg experience
- 3+ years of experience as an RN
- 1+ year of inpatient hospital experience
- Active, current, and unrestricted RN licensure in state of residence
- Ability to work in multiple IT platforms/systems
- 1+ year of experience with Microsoft Office applications (Outlook, Teams, Excel)
- Associates Degree required
- Experience with Medicare/Medicaid populations preferred
- MCG experience preferred
- Managed care experience preferred
- UM Certification preferred
- MedCompass preferred
- 1+ year of inpatient utilization experience preferred
- Availability to work weekends, holidays, and evening hours as part of a 24/7 operation
- Direct/hardwired internet connection to a modem/router within 7 feet of the computer
- Minimum internet speed of 25 Mbps download and 3 Mbps upload
- Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently residing
- Ability to obtain required internet speeds and adhere to Work From Home requirements
- Ability to set up and use multiple monitors and navigate multiple applications
- Ability to use digital communication tools, email, calendar invites, Teams messaging, and virtual meetings
- Experience with Microsoft Office 365 applications or similar Google Workspace applications
- Ability to log in to secure systems such as VPN and EHR portals, secure devices, manage strong passwords, and recognize suspicious emails or links
- Ability to troubleshoot common technical issues independently
- Openness to learning new skills as the workplace evolves
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
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)