UM Nurse
HumanaSalary not specified
Full Time
Mid-level (3 to 4 years)
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Pharmacy, RetailIndustries
Requirements
Candidates must possess 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 mandatory. An Associate's Degree is required, with a BSN preferred. Managed care experience, particularly in Utilization Management, is preferred, with a preference for candidates residing in EST time zones.
Responsibilities
The Utilization Management Nurse Consultant will utilize clinical experience to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits for members. This role involves gathering clinical information, applying appropriate criteria and guidelines to make coverage determinations, and communicating with providers. Responsibilities also include identifying members for referral opportunities, promoting quality and effectiveness of healthcare services, and consulting with internal and external constituents. The role requires proficiency in computer skills, effective communication, and the ability to multitask in a fast-paced environment, with work schedules including weekends, holidays, and evening hours.
Skills
Clinical Assessment
Care Planning
Healthcare Services
Benefit Utilization
Clinical Criteria Application
Coverage Determination
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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