Full-Time

Utilization Management Nurse Consultant

Posted on 1/16/2025

CVS Health

CVS Health

10,001+ employees

Comprehensive pharmacy and healthcare services

Healthcare
Consumer Goods

Compensation Overview

$26.01 - $56.14Hourly

+ Bonus + Commission + Short-term Incentive Program

Mid

Company Historically Provides H1B Sponsorship

Remote in USA

Candidate must live in the eastern time zone.

Category
Nursing & Allied Health Professionals
Medical, Clinical & Veterinary

You match the following CVS Health's candidate preferences

Employers are more likely to interview you if you match these preferences:

Degree
Experience
Requirements
  • RN with active and unrestricted state licensure
  • 3+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience
  • Must live in Eastern time zone
Responsibilities
  • 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.
  • Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
  • 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.
Desired Qualifications
  • 1+ years’ experience Utilization Review experience
  • 1+ years’ experience Managed Care
  • Strong telephonic communication skills
  • 1+ years’ experience with Microsoft Office Suite

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. The company serves individual consumers, businesses, and communities, offering prescription medications, over-the-counter health products, beauty items, and general merchandise. CVS Health also functions as a pharmacy benefits manager, managing health plans for over 75 million members, and provides specialized care for seniors and patients requiring specialty medications. This integrated approach allows CVS Health to enhance access to healthcare, improve health outcomes, and reduce costs. Unlike many competitors, CVS Health combines retail pharmacy services with clinical care, making it a significant player in the healthcare sector with a goal of helping people achieve better health.

Company Stage

Debt Financing

Total Funding

N/A

Headquarters

Woonsocket, Rhode Island

Founded

1963

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Simplify's Take

What believers are saying

  • Expansion of telehealth services allows CVS to reach more patients remotely.
  • Increased consumer interest in wellness boosts demand for CVS's health-related products.
  • The trend towards value-based care aligns with CVS's integrated healthcare approach.

What critics are saying

  • Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.
  • The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.
  • The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

What makes CVS Health unique

  • CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.
  • The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.
  • CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

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Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

INACTIVE