Utilization Management Nurse Consultant

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Position Summary

Utilization management is a 24/7 operation.  Work schedules will include weekends and holidays and evening rotations.

As a Utilization Management Nurse Consultant you will be responsible for the review and evaluation of clinical information and documentation related to outpatient therapy services. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for customer service and claims processing areas

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care

• Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs

• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• Typical office working environment with productivity and quality expectations.

• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

• Sedentary work involving periods of sitting, talking, listening.

• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

• Effective communication skills, both verbal and written

Required Qualifications

• 3+ years of experience as a Registered Nurse

• Must have active current and unrestricted RN licensure in state of residence

• 1+ years of clinical experience in acute or post-acute setting

• Must be willing and able to work Monday through Friday 8:00am to 5pm CST or 9:00am to 6:00pm EST. Utilization management is a 24/7 operation.  Work schedules will include a minimum of 6 weekend rotations per year, as well as holidays and evening rotations.

Preferred Qualifications

• Candidates in CST or MST highly preferred

• Managed care experience

• Discharge planning experience

• Utilization Management experience

Education
Associates or equivalent degree required
BSN preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $56.14

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to