Remote Utilization Nurse Consultant (Medical Review)

CVS Health; Missouri; Hybrid; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant (Medical Review) to ensure members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote role leverages your clinical expertise in a fast-paced, desk-based environment.

Join a team making a difference in patients’ complex journeys. The role requires RN licensure, 3+ years of clinical experience, and 1+ year in Utilization/M medical management, with a 3-week

Qualifications

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges.
• Ability to obtain licensure in non-compact states as needed.
• Minimum 3 years of clinical experience.
• 5 years demonstrated to make thorough independent decisions using clinical judgement.
• 5 years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.
• 1+ Year of Utilization Review Management and/or Medical Management experience.
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

Responsibilities

• Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.
• Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.
• Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines.
• Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.
• Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.
• Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.
• Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.
• Must be able to work independently without personal distractions to meet quality and metric expectations.

Skills

RN license

Clinical experience

Independent decision making

Utilization Review

Training participation

Education

Associate’s degree in nursing

BSN preferred

Tools

Electronic health records

Clinical documentation systems

Job description

CVS Health is seeking a Utilization Management Nurse Consultant (Medical Review) to ensure members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote role leverages your clinical expertise in a fast-paced, desk-based environment.

Join a team making a difference in patients’ complex journeys. The role requires RN licensure, 3+ years of clinical experience, and 1+ year in Utilization/M medical management, with a 3-week