Utilization Review Clinician
WellSkySalary not specified
Full Time
Mid-level (3 to 4 years)
Not SpecifiedCompensation
Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Health Insurance, PharmacyIndustries
Requirements
Candidates must have at least 3 years of experience as a Registered Nurse in a clinical setting and possess an active, current, and unrestricted RN license in their state of residence. The role requires the ability to work Monday through Friday, 8:00 am to 5:00 pm CST, with potential weekend/holiday coverage. An Associate Degree is required, and a BSN is preferred. Proficiency in computer skills, including navigating multiple systems and keyboarding, is essential, as are effective verbal and written communication skills.
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 assessing, planning, implementing, coordinating, monitoring, and evaluating options to facilitate appropriate healthcare services and benefits for members. The role requires gathering clinical information, applying appropriate clinical criteria, policies, and judgment to render coverage determinations, and communicating with providers to facilitate care. Additionally, the consultant will identify members for referral opportunities, promote quality and effectiveness of healthcare services, and consult with internal and external constituents to administer the utilization/benefit management function.
Skills
Clinical Skills
Utilization Management
Benefit Management
Healthcare Services
Communication
Coordination
Assessment
Planning
Monitoring
Evaluation
Clinical Judgment
Provider Communication
Quality Improvement
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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