Utilization Management Nurse Consultant- must live in Louisiana id-10336
- Full-Time
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.
Position Summary
Concurrent Review
This role is work from home with the following hours: Monday-Friday 8am-5pm CST, with ability to work rotating on call, weekend/holiday coverage.
- Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.
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- Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
- Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
- Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
- Identifies members who may benefit from care management programs and facilitates referral
- Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
Required Qualifications
-3+ years of clinical practice experience in an inpatient setting required
- 5+ years of experience as a Registered Nurse
- Must have active current and unrestricted LA or compact state licensure
- Willingness to obtain additional state licenses
- Must have the ability to work 8am - 5pm CST with rotating holiday/weekends
- Must have MS Office Suites experience
Preferred Qualifications
- Managed care/utilization review experience preferred
- Discharge planning experience preferred
Education
Associate of Nursing
BSN preferred
Anticipated Weekly Hours
