PRN Utilization Review Nurse Reviewer
Blank StreetSalary not specified
Full Time
Mid-level (3 to 4 years), Senior (5 to 8 years)
Utilization Management Nurse Consultant - Medical Review (Remote) at CVS Health
Michigan City, Mississippi, United States
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Health InsuranceIndustries
Requirements
- Active, unrestricted RN license in state of residence with multistate/compact licensure privileges; ability to obtain licensure in non-compact states as needed
- Minimum 3 years of clinical experience
- 5 years demonstrated ability to make thorough independent decisions using clinical judgement
- 5 years proficient use of equipment including phone, computer, etc., and clinical documentation systems
- 1+ year of Utilization Review Management and/or Medical Management experience
- Commitment to attend mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation
- Associate's degree in nursing (RN) required, BSN preferred
- Dedicated workspace free of interruptions for remote work; dependents must have separate care arrangements during work hours
Responsibilities
- Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor, and evaluate medical review cases
- Applies appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client
- Applies critical thinking, evidence-based clinical criteria, and clinical practice guidelines to authorize procedures/services or initiate Medical Director referral as needed
- Assists management with training new nurse reviewers/business partners or vendors, including initial and ongoing mentoring and feedback
- Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs
- Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc., that enhance production, quality, and client satisfaction
- Works independently without personal distractions to meet quality and metric expectations
- Participates in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
Is this position remote?
Yes, this is a 100% remote role available only to candidates in the U.S., requiring a dedicated workspace free of interruptions and separate care arrangements for dependents during work hours.
What are the required qualifications for this role?
Candidates must have an active, unrestricted RN license in their state of residence with a multistate/compact license.
What is the work schedule like?
The schedule is Monday–Friday 8:00am-5:00pm EST, though shift times may vary based on business needs, and it includes occasional on-call rotations with some weekends and holidays.
What skills are essential for success in this role?
Key skills include clinical expertise for medical review, critical thinking, applying evidence-based criteria and guidelines, collaboration with providers, and the ability to work independently without distractions.
What does the company culture or team environment look like?
The team is collaborative, focused on making a difference in patients' lives through high-quality care management, with emphasis on precision, communication, compassion, mentoring, cross-training, and process improvements.
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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