We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Fully remote with requirement to work the following schedule: Monday-Friday 8:00am-4:30pm EST. Position Summary 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. The UM Nurse Consultant job duties include (not all encompassing): • 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.
CVS Health/Aetna hires nurses for remote positions in health plan administration and virtual care delivery. Roles include Appeals Nurse Consultants who review clinical complaints and appeals for Medicare/Medicaid plans while ensuring regulatory compliance; Utilization Management Nurse Consultants who review services for medical necessity, coordinate discharge planning, and collaborate with providers to ensure appropriate care; and MinuteClinic Virtual Care Nurse Practitioners who provide direct patient care through a remote platform for patients 18 months and older. These positions require clinical expertise to support members in receiving safe, appropriate, and cost-effective care while meeting state and federal requirements.
