Utilization Management Nurse Consultant

Decker Jones, P.C.; Athens (GA); On-site; Full time

Job summary

A leading health solutions company is seeking a Clinical Precertification RN for its Utilization Management team. The role involves assessing and coordinating appropriate healthcare services while ensuring members receive the benefits they need. Applicants should have a strong clinical background and be prepared for a 24/7 operational role including evening shifts.

Benefits

401(k) plan with company matching

Employee stock purchase plan

Wellness programs

Flexible work schedules

Tuition assistance

Qualifications

• 3+ years as a Registered Nurse.
• Active RN licensure in state of residence.
• 1+ years of Med/Surg experience.

Responsibilities

• Assess and plan healthcare services for members.
• Gathers clinical information for coverage determinations.
• Communicates with providers to facilitate treatment.

Skills

Communication

Clinical Assessment

Coordination

Education

Associates degree

BSN preferred

Tools

Microsoft Office

MedCompass

Job description

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

Clinical Precertification: Medicare

Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

• 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 members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicates 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 utilization
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Required Qualifications

• 3+ years of experience as a Registered Nurse
• Must have active current and unrestricted RN licensure in state of residence
• 1+ years of Med/Surg experience
• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
• Must be willing and able to work Monday through Friday, 9:00am to 5:30pm EST with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

Preferred Qualifications

• Prior Authorization or Utilization Management experience
• Managed care experience
• Experience using MedCompass
• Ambulatory surgery experience

Education

Associates degree required

BSN preferred

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$26.01 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 06/10/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.