Utilization Management Nurse Consultant

CVS Health; Illinois; Hybrid; USD 44,083 - 95,054; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Paid time off

Job summary

The Hispanic Alliance for Career Enhancement seeks an RN for Utilization Management in a 24/7 operation, including weekends, holidays, and evenings. You will assess, plan, coordinate, and evaluate options to ensure appropriate healthcare services and benefits for members, using clinical judgment and guidelines.

Requirements include 2+ years as an RN in adult acute/critical care, active RN license, and associates degree (BSN preferred).

Qualifications

• 2+ years of experience as a Registered Nurse in adult acute/critical care.
• Active current and unrestricted RN licensure in state of residence.
• Utilization Management is a 24/7 operation with variable hours.

Responsibilities

• Assess, plan, implement, coordinate, monitor and evaluate care options for members.
• Gather clinical information and apply criteria and guidelines to render coverage decisions.
• Communicate with providers to facilitate care and identify referral opportunities.
• Identify opportunities to improve quality and effectiveness of healthcare services and benefit utilization.
• Collaborate with internal and external stakeholders in utilization management.

Skills

Registered Nurse (RN)

Clinical assessment

Coordination

Communication skills

Education

Associate degree

BSN preferred

Job description

Position Summary

Utilization Management is a 24/7 operation and work schedules will include weekends, 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.
• Typical office working environment with productivity and quality expectations.
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written.

Required Qualifications

• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting.
• Must have active current and unrestricted RN licensure in state of residence.
• Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.

Preferred Qualifications

• 2+ years of clinical experience required in med surg or specialty area.
• Managed Care experience preferred, especially Utilization Management.
• Preference for those residing in CT zones.

Education

Associates Degree required.

BSN preferred.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $32.01 - $68.55.

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.

Benefits

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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