[Remote] Utilization Management Nurse Consultant at CVS Health

Virginia, Minnesota, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must possess an active, unrestricted RN license in their state of residence and have at least 3 years of acute hospital clinical experience as an RN. A minimum of 1 year of experience with MS Office suites, including Outlook and Excel, is required. Preferred qualifications include utilization review experience, managed care experience, strong customer service skills, and excellent telephonic communication skills. An Associate's Degree in Nursing or a Diploma RN is required, with a BSN being preferred. The role requires availability to work Monday through Friday from 8 am to 5 pm EST, with occasional on-call weekend and holiday rotations.

Responsibilities

The Utilization Management Nurse Consultant will utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. This involves ensuring members receive appropriate care, at the right time, and in the correct location according to designated criteria and federal/state regulations, including reviewing clinical records. The role also includes using clinical tools and data to review services for medical necessity, applying clinical expertise for appropriate benefit utilization, facilitating safe discharge planning, and collaborating with facilities and providers to meet member needs.

Skills

RN license

Acute hospital clinical experience

MS Office

Outlook

Excel

Utilization review

Clinical documentation

Communication

Teamwork

Detail-oriented

Organization

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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