Utilization Management Nurse Consultant - Work at Home - Eastern Standard Hours at CVS Health

Idaho, 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

3+ years clinical practice experience as a Registered Nurse preferably in an acute setting (ex: OR, ER, ICU, med surg, home health, pediatrics, NICU, PICU)
Must have current active and unrestricted RN licensure in state of residence
Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours
2+ years of experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
Associates degree required (BSN preferred)
Resides in Pennsylvania (preferred)
Proficiency with computer skills which includes navigating multiple systems and keyboarding required

Responsibilities

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program
Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
Identifies members who may benefit from care management programs and facilitates referral
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

Skills

Utilization Management

Clinical Nursing

Medical Necessity Criteria

Care Coordination

Evidence-Based Care

Discharge Planning

Triage

Computer Proficiency

Keyboarding

Critical Thinking

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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