Utilization Management Nurse Consultant

About the role

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.

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.
• Performs close inspection of hand written and computer generated documents as well as a PC monitor.
• Sits for extended periods, talks on the telephone and types on the computer.
• Multitasks, prioritizes and effectively adapts to a fast-paced changing environment.

Qualifications

• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting.
• 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.

Preferred Qualifications

• 2+ years of clinical experience required in med surg or specialty area.
• Managed Care experience preferred, especially Utilization Management.
• Preference for those residing in MST/PST zones.

Education

• Associates Degree required.
• BSN preferred.

Pay

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.