CVS Health Utilization Management Nurse Consultant RN in Ohio
Required schedule 1130am-800pm ET. Weekend/holiday coverage will occasionally be required. Requires an RN with unrestricted active license.This is a telework role.Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. 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 membersGathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render determination/recommendation along the continuum of careCommunicates 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 utilizationConsults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Ability to demonstrate and explain past experience delivering exemplary customer service for both internal and external customers required3-5 years of clinical experience requiredRN with current unrestricted state licensure requiredWeekend/holiday coverage will occasionally be requiredRequires 1130am-800pm shift for at least first 12 months post completion of orientation period and work in clinical telephone queue working with providers to secure additional information for prior authorization review
Managed Care experience preferredPrior demonstrated experience working in a high volume clinical call center environment preferredUtilization Management experience preferred
Associate's degree or equivalent experience
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.