A1A UM Nurse Consultant

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose‑driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

• 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.

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

Registered Nurse (RN) required.

3-5 years

• 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.

40

Full time

The typical pay range for this role is:
$26.01 - $68.55

This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable…