Utilization Management Clinical Nurse Consultant (Must be licensed in Arizona)

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.

The Utilization Management Clinical Nurse Consultant utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.

Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care. Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members. Coordinates and communicates with providers and other parties to facilitate optimal care/treatment. Identifies members who may benefit from care management programs or other post-discharge programs and facilitates referrals. Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.