Utilization Review Clinician
WellSkyFull Time
Mid-level (3 to 4 years)
Candidates must have at least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting. A current and unrestricted RN license in the state of residence is required. An Associate's Degree is required, with a BSN preferred. Experience in medical-surgical or a specialty area, as well as managed care or utilization management experience, is preferred. The role requires proficiency in computer skills, including navigating multiple systems and keyboarding, along with effective verbal and written communication skills. Work schedules will include weekends, holidays, and evening hours as Utilization Management is a 24/7 operation.
The Utilization Management Nurse Consultant will utilize clinical experience and skills to assess, plan, implement, coordinate, monitor, and evaluate options for healthcare services and benefits. This includes gathering clinical information, applying clinical criteria and guidelines, and rendering coverage determinations. Responsibilities also involve communicating with providers, identifying members for referral opportunities, promoting quality and effectiveness of healthcare services, and consulting with internal and external constituents to administer the utilization/benefit management function.
Comprehensive pharmacy and healthcare services
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.