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

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgement to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage/crisis support).
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs and facilities referrals.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

Required Qualifications

• Must have active, current, and unrestricted RN licensure in state of residence
• Must be available to work M-F; 8am-5pm EST
• Must be willing and able to work occasional rotating weekend and holidays
• Willingness to obtain additional state licenses
• 3+ years of clinical practice experience in an inpatient setting as an RN
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Preferred Qualifications

• Knowledge or clinical practice experience in a post acute facility ( Skilled nursing, Rehabilitation, Long Term Acute Care)

Education

• Associates Degree required
• BSN preferred

Pay Range

The typical pay range for this role is: $30.39 – $65.66.

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 into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 05/03/2024.