Utilization Management Nurse Consultant

Maitland, Florida, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Pharmacy, Health InsuranceIndustries

Requirements

Candidates must have at least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting. An active, current, and unrestricted RN license in the state of residence is required. A minimum of an Associate's Degree is necessary, with a BSN being preferred. Two or more years of clinical experience in a med surg or specialty area is preferred, as is managed care experience, particularly in Utilization Management. Preference will be given to candidates residing in EST time zones.

Responsibilities

The Utilization Management Nurse Consultant will utilize clinical experience to assess, plan, implement, coordinate, monitor, and evaluate options for healthcare services and benefits. This role involves gathering clinical information, applying clinical criteria and judgment to make coverage determinations, and communicating with providers. The consultant will identify members for referral opportunities, promote quality and effectiveness of healthcare services, and consult with internal and external constituents regarding utilization management. The position requires the ability to work in a 24/7 operation, including weekends, holidays, and evenings, and involves sedentary work with significant computer use and multitasking.

Skills

Clinical Assessment

Care Planning

Healthcare Services Coordination

Benefit Utilization

Clinical Criteria Application

Provider Communication

Quality Improvement

Multitasking

Prioritization

Adaptability

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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