Utilization Management Nurse Consultant

Texas Twp, Michigan, 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 have at least 3 years of experience as a Registered Nurse, with 1+ years in Med/Surg and 1+ years using Microsoft Office applications. An active, unrestricted RN license in the state of residence is mandatory. An Associate's degree is required, and a BSN is preferred. Prior Authorization or Utilization Management experience and experience using MedCompass are preferred qualifications.

Responsibilities

The Utilization Management Nurse Consultant will utilize clinical experience to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits. This role involves gathering clinical information, applying appropriate criteria for coverage determinations, and communicating with providers. The consultant will also identify members for referral opportunities, promote quality and benefit utilization, and consult with internal and external constituents on utilization management functions. This is a full-time position requiring availability for evening hours and holidays as part of a 24/7 operation.

Skills

Registered Nurse

RN licensure

Med/Surg

Microsoft Office

Outlook

Teams

Excel

Clinical assessment

Care planning

Healthcare services

Benefit utilization

Utilization management

Precertification

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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