RN, Utilization Management - Care Coordination & Outcomes

CVS Health; City of Albany (NY); Remote; USD 91,610,000 - 196,424,000; Full time

Job summary

CVS Health is seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services.

You will collaborate with providers, care teams and internal partners to coordinate treatment, identify opportunities to improve quality and benefit utilization, and refer members to programs that support their health needs.

Qualifications

• Active RN license in the state of residence.
• 2+ years RN experience in adult acute or critical care.
• Associate degree in nursing (ADN).
• Strong communication, multitasking and computer navigation skills.
• Ability to work 8:00 AM–5:00 PM ET, including on weekends/holidays as needed.
• BSN preferred.
• Med-Surg or specialty area experience.
• Managed Care or Utilization Management experience.
• Eastern Time Zone location preferred.

Responsibilities

• Review clinical information and apply criteria to support coverage decisions.
• Collaborate with providers and care teams to coordinate treatment and services.
• Identify opportunities to improve quality and utilization of benefits.
• Refer members to programs and services that support health needs.
• Serve as a clinical resource for utilization and benefit management questions.

Skills

RN license

RN experience

Communication

Multitasking

Computer navigation

Med-Surg experience

Utilization Management

Eastern Time Zone

Education

Associate Degree in Nursing

BSN (preferred)

Tools

Microsoft Office 365

Job description

CVS Health is seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services.

You will collaborate with providers, care teams and internal partners to coordinate treatment, identify opportunities to improve quality and benefit utilization, and refer members to programs that support their health needs.