Utilization Management Nurse Consultant Job at CVS Health in Charleston

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.**Position Summary**This is a fully remote Utilization Management Nurse Consultant opportunity. The schedule is Monday through Friday, 8am to 5pm EST time zone where the candidate resides. **.**Responsible for the review and evaluation of clinical information and documentation related to outpatient therapy services. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for customer service and claims processing areas.+ Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.+ Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care+ Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs+ Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization+ Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.+ Typical office working environment with productivity and quality expectations.+ Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.+ Sedentary work involving periods of sitting, talking, listening.+ Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.+ Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.+ Effective communication skills, both verbal and written**Required Qualifications**+ 2+ years of clinical experience as an RN+ 2+ years of inpatient experience+ Must have active, current, and unrestricted RN licensure in state of residence+ 1 + years of experience using Microsoft Office products, including Teams, Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews**Preferred Qualifications**+ Experience with ASD, MedCompass, IOP, or clinical review experience with therapy review types+ Experience working with adults and/or pediatrics outpatient therapy, i.e. occupational therapy, physical therapy, speech therapy, chiropractic, or acupuncture+ Experience working in a multidisciplinary team**Education**Associates degree requiredBSN preferred**Pay Range**The typical pay range for this role is:$26.01 - $56.14This 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.In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)We anticipate the application window for this opening will close on: 11/04/2024Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.