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.

Position Summary Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.

Family Summary/Mission

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Job Description

Primary Job Duties & Responsibilities 

Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members. 

Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services. 

Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources. 

Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies. 

Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization. 

Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function. 

Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes. 

Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making. 

Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance. 

Education 

Bachelor's degree preferred/specialized training/relevant professional qualification. 

Prior Relevant Work Experience 

3-5 years 

Essential Qualifications 

Working knowledge of problem solving and decision making skills. 

Working knowledge of medical terminology. 

Working knowledge of digital literacy skills. 

Ability to deal tactfully with customers and community. 

Ability to handle sensitive information ethically and responsibly.  

Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option. 

Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients. 

Registered Nurse (RN) required.

Position Summary 

This Utilization Management (UM) Nurse Consultant role is 100% remote and the candidate can live in any state. 

Working Hours: Monday through Friday 8:30am-5:00pm in the time zone of residence. Shift times may vary occasionally per the need of the department.  Rotational late shift 9:30am - 6:00pm CST. 

No travel is required. 

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. 

The UM Nurse Consultant job duties include (not all encompassing): 

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. 
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. 
• 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. 
• Required Qualifications 
  RN with active and unrestricted state licensure in their state of residence 
  2+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience (team is not accepting applicants whose only acute care experience is in behavioral health) 
    
  Preferred Qualifications 
  1+ years’ experience Utilization Review experience 
  1+ years’ experience Managed Care  
  Strong telephonic communication skills 
  1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook) 
  Experience with computers toggling between screens while using a keyboard and speaking to customers. 
  Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills 
  Ability to manage multiple priorities, effective organizational and time management skills required 
  Ability use a computer station and sit for extended periods of time 
    
  Education 
  Associate Degree in Nursing is minimum required, BSN preferred. 

Anticipated Weekly Hours

40

Job Grade

207

Anticipated Weekly Hours

Time Type

Pay Range

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.