Utilization Management Nurse Consultant
| Company | CVS Health |
|---|---|
| Location | Washington, USA, Pennsylvania, USA, Delaware, USA, Washington, DC, USA, Jackson Township, NJ, USA, Florida, USA, Waterbury, CT, USA, South Carolina, USA, Georgia, USA, Virginia, USA, Rhode Island, USA, New York, NY, USA, Maryland, USA, North Carolina, USA, Ohio, USA |
| Salary | $26.01 – $56.14 |
| Type | Full-Time |
| Degrees | Bachelor’s |
| Experience Level | Mid Level, Senior |
Requirements
- Must reside in EST zone
- 3+ years of clinical experience as a Registered Nurse in a hospital setting including Medical/Surgical, Emergency room, Critical Care, ICU, and/or step-down unit
- 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 5:00pm EST with a late shift rotation 10:30am to 7pm EST. Utilization management is a 24/7 operation. Work schedules may include weekends and holidays and evening rotations.
Responsibilities
- 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.
Preferred Qualifications
- Utilization review experience
- Medicare experience
- Managed Care experience
- Proficiency with computer skills which includes navigating multiple systems and keyboarding