Utilization Management Nurse Consultant

Illinois, 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, Health InsuranceIndustries

Requirements

Candidates must have at least 3 years of experience as a Registered Nurse (RN) and hold an active, unrestricted RN license in their state of residence. A minimum of 1 year of experience with Microsoft Office Applications (Outlook, Teams, Excel) and the ability to work across multiple IT platforms are required. An Associate's Degree in Nursing is mandatory, with a BSN being preferred. Candidates must also be willing to work 8 am to 5 pm local time. Prior authorization utilization experience, outpatient clinical experience, and knowledge of Medicare/Medicaid are preferred. Experience within managed care and residing in the Central time zone are also preferred qualifications.

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 and applying appropriate criteria, guidelines, policies, and clinical judgment to make coverage determinations. Responsibilities include communicating with providers, identifying members for referral opportunities to integrate with other products and services, and recognizing opportunities to enhance the quality and effectiveness of healthcare services and benefit utilization. The consultant will also provide expertise and consultation to internal and external constituents regarding the utilization and benefit management functions.

Skills

Clinical Assessment

Care Coordination

Coverage Determination

Healthcare Services

Benefit Utilization

Microsoft Office Suite

Outlook

Teams

Excel

Prior Authorization

Outpatient Clinical

Medicare

Medicaid

Managed Care

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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