[Hiring] A1A UM Nurse Consultant @CVS Health

Role Description

This role involves driving 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.

Qualifications

• Bachelor's degree preferred/specialized training/relevant professional qualification.
• Registered Nurse (RN) required.
• 3-5 years of relevant work experience.

Requirements

• 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.

Benefits

• Affordable medical plan options.
• 401(k) plan (including matching company contributions).
• Employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.