Utilization Management Nurse Consultant

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

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

• 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

• Must reside within the Eastern or Central time zone

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

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

• 3+ years of clinical hospital experience as a Registered Nurse in Medical/Surgical, Emergency room, Critical Care, ICU, or step-down unit

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

• 2+ years of proficiency with computer skills which includes navigating multiple systems and keyboarding

• 1+ year experience with MS office applications including Teams, Outlook, Word, and Excel

Preferred Qualifications

• Managed Care experience

• Utilization review experience

• Experience working with Medicare members

• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment 

Education

• Associates degree or equivalent required

• BSN preferred

Pay Range

The typical pay range for this role is:

$32.01 - $68.55

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 your compensation, enjoy the rewards of an organization that puts our heart