Utilization Nurse Consultant Clinical Team Lead

Company	CVS Health
Location	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, West Virginia, USA, New York, NY, USA, Maryland, USA, North Carolina, USA
Salary	$60522 – $129615
Type	Full-Time
Degrees	Bachelor’s
Experience Level	Mid Level, Senior

3+ years of experience as a Registered Nurse in adult acute care/critical care setting
1+ years of Managed Care Experience
Must have active current and unrestricted RN licensure in state of residence
Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours

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
Analyzes reports for assignments/trends/metrics/issues
First in line for questions from frontline staff on cases
May be required to proctor RN/MD rounds
Assists with escalated case reviews/facility issues
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