Utilization Management Nurse Consultant

Location: Alaska

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Job Description Summary Assesses and monitors patient health, administering medications and treatments, performing medical procedures, and collaborating with physicians and other healthcare professionals to develop and implement patient care plans. Educates patients and their families about healthcare management and assists in maintaining a safe and supportive healthcare environment.

Job Description Primary

Job Duties & Responsibilities Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.

Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services.

Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.

Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.

Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.

Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.

Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.

Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making.

Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.

Education Bachelor's degree preferred/specialized training/relevant professional qualification.

Prior Relevant Work Experience3-5 years

Essential Qualifications Working knowledge of problem solving and decision making skills.

Working knowledge of medical terminology.

Working knowledge of digital literacy skills.

Ability to deal tactfully with customers and community.

Ability to handle sensitive information ethically and responsibly.

Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.

Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.

Registered Nurse (RN) required.

Licensed Clinical Social Worker (LCSW) preferred.

Requisition

Job Description Position Summary This Utilization Management (UM) Nurse Consultant role is 100% remote and the candidate can live in any state.

Normal

Working Hours:

Monday through Friday 8:30am-5:00pm in the time zone of residence. Shift times may vary occasionally per the need of the department. Rotational late shift 9:30-6

CST.No travel is required.

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and…