Utilization Management Nurse Consultant

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.\n\nAs 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.\n\nPosition Summary\n\nCVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization / benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.\n\nKey Responsibilities of the UM Nurse Consultant (Includes but is not limited to)\n

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.\n
• Facilitate the delivery of appropriate benefits and / or healthcare information which determines eligibility for benefits while promoting wellness activities.\n
• Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.\n
• 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.\n
• 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.\n
• 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.\n
• Communicates with providers and other parties to facilitate care / treatment.\n
• Identifies members for referral opportunities to integrate with other products, services and / or programs.\n
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.\n\nRequired Qualifications\n
• Registered Nurse (RN) with current unrestricted US licensure required.\n
• 2+ years clinical practice experience as an RN required.\n
• 2+ Years Utilization Management experience.\n
• Must be willing to travel to the local office as needed if living within approximately 45 minutes / miles.\n\nPreferred Qualifications\n
• Bilingual proficiency preferred.\n
• 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications.\n\nEducation\n
• Associate's degree in Nursing.\n
• BSN preferred.\n\nAnticipated Weekly Hours\n40\n\nTime Type\nFull time\n\nPay Range\n\nThe typical pay range for this role is : \n\n$26.01 - $74.78\n\nThis 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.\n\nOur 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.\n\nGreat benefits for great people\n\nWe 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 : \n
• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.\n
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.\n
• 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.\n\nFor more information, visit https : / / jobs.cvshealth.com / us / en / benefits\n\nWe anticipate the application window for this opening will close on : 11 / 07 / 2025\n\nQualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.