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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 .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and clinical assessment, with a strong focus on coordinating healthcare services and benefits for members. Proficient in applying clinical criteria and guidelines while effectively communicating with providers and stakeholders.
Highest-signal resume keywords
Registered Nurse LicensureUtilization Management ExperienceMed/Surg ExperienceMicrosoft Office ApplicationsPrior Authorization Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentCoverage DeterminationHealthcare Service CoordinationClinical Criteria ApplicationBenefit ManagementTroubleshooting Technical IssuesVPN AccessEHR Portal NavigationAmbulatory Surgery ExperienceMedCompass Experience
Soft Skills
Effective CommunicationCollaborationOpenness to LearningOrganizational SkillsAttention to Detail
Tools & Technologies
Microsoft Office 365Google WorkspaceTeamsOutlookExcel
Certifications & Qualifications
Active RN LicensureAssociates Degree
Industry Keywords
Utilization ManagementManaged CareHealthcare ServicesClinical GuidelinesHIPAA Compliance
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 and programs
- Identify opportunities to promote healthcare service quality and benefit utilization
- Consult and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
- Work collaboratively within a 24/7 Utilization Management operation
Requirements
What you’ll need- 3+ years of experience as a Registered Nurse
- Active, current and unrestricted RN licensure in state of residence
- 1+ years of Med/Surg experience
- 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
- Willingness and ability to work Monday through Friday, 9:00am to 5:30pm eastern or central time, with occasional holiday rotation
- Utilization Management schedules may include holidays and evening hours
- Prior Authorization or Utilization Management experience preferred
- Managed care experience preferred
- Experience using MedCompass preferred
- Ambulatory surgery experience preferred
- Associates degree required
- 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 virtual work location compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently living
- Must provide workspace furniture
- Ability to set up and use multiple monitors and navigate multiple applications
- Ability to communicate via email, calendar invites, Teams messaging and virtual meetings
- Experience with Microsoft Office 365 or similar Google Workspace applications
- Ability to access secure systems such as VPN and EHR portals
- Ability to follow computer and password security practices and recognize suspicious emails or links
- Ability to troubleshoot common technical issues independently
- Openness to learning new skills
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 colleagues’ physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)