[Remote] Utilization Management Nurse Consultant - Work at Home at CVS Health

Texas Twp, Michigan, 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

HealthcareIndustries

Requirements

RN with active and unrestricted state licensure in state of residence
2+ years of acute hospital clinical experience as an RN (preference for medical-surgical and ICU experience)
Reliable phone and hard-wired internet service for work at home
Ability to work Mon–Fri 8:30-5:00 PM in your time zone (shift times may vary, including rotational late shift 9:30-6:00 PM CST)
Reachable via phone, videoconference, and email during work hours (8 hours per day)
Secure and private work environment to maintain confidentiality (HIPAA compliant)
Sedentary position; able to sit for long periods of time
Proficient in multisystem navigation (comfortable using multiple monitors and systems simultaneously)
Effective multitasker (skilled at talking and typing concurrently while managing responsibilities with focus and accuracy)
Basic technical troubleshooting (able to set up/connect hardware like monitors/keyboards and resolve common issues independently)
Personal responsibilities, including dependent care, must not interfere with work duties (dependent care generally not allowed during work hours)

Responsibilities

Review services to assure medical necessity and apply clinical expertise to assure appropriate benefit utilization
Facilitate safe and efficient discharge planning and work closely with facilities and providers to meet complex member needs
Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program
Utilize clinical experience in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options for appropriate healthcare services/benefits
Gather clinical information and apply clinical criteria/guidelines, policy, procedure, and judgment to render coverage determinations/recommendations along the continuum of care
Communicate with providers and other parties to facilitate care/treatment
Identify members for referral opportunities to integrate with other products, services, and/or programs
Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization
Consult and lend expertise to internal and external constituents in the coordination and administration of utilization/benefit management
Ensure member receives appropriate care at the appropriate time and location, adhering to federal and state regulated turn-around times, including reviewing written clinical records

Skills

Utilization Management

Medical Necessity Review

Discharge Planning

Clinical Documentation

Care Coordination

Clinical Criteria Application

Healthcare Benefits

Provider Communication

Nursing

Case Management

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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