Utilization Management Nurse Consultant

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Medicare Clinical Predetermination Nurse

• 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.

• 3+ years of experience as a Registered Nurse

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

• 1+ years of Med/Surg experience

• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)

• Must be willing and able to work Monday through Friday, 9:00am to 5:30pm eastern or central time with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

• Prior Authorization or Utilization Management experience

• Managed care experience

• Experience using MedCompass

• Ambulatory surgery experience

Associates degree required

BSN preferred

The typical pay range for this role is:

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.