Senior Manager, Performance Partners
BD
Utilization Management Nurse Consultant - Work From Home
CVS Health
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $26 - $56 per hour
Job Level
Mid-LevelSenior
About the role
- Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification.\n
- The majority of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers.\n
- Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.\n
- This position will be working regular business hours with potential for occasional weekend/holiday on-call.\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
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.\n
- Typical office working environment with productivity and quality expectations.
Requirements
- Must have active, current, and unrestricted compact RN licensure in state of residence\n
- 3+ years of clinical experience required\n
- 1+ years of Microsoft Office Suite experience required\n
- Position requires proficiency with computer skills which includes navigating multiple systems\n
- Ability to work in a fast paced environment\n
- Sedentary work involves periods of sitting, talking, listening and computer use\n
- Education: Associate's degree required; BSN preferred\n
- Anticipated Weekly Hours: 40\n
- Prior Authorization experience strongly preferred
