RN Call Center - Post Acute PRN
SSM Health
Utilization Management Nurse Consultant
CVS Health
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $29 - $62 per hour
Job Level
Mid-LevelSenior
About the role
- 100% remote position from anywhere in the U.S. Work hours: 11:30am-8:00pm EST, Monday-Friday. Weekend/holiday coverage will occasionally be required. 100% attendance is required during the first 3 weeks of training / 8:30am-5pm EST, Monday-Friday.
- American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management.
- Work in clinical telephone queue for 3 to 4 hours a day working with providers to secure additional information for prior authorization review.
- This candidate will utilize 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 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.
- WFH and hybrid Colleagues must manage dependent care and other personal responsibilities in a way that allows them to successfully meet job responsibilities while working from their virtual work location.
Requirements
- 1 year of varied UM (utilization management) experience within an outpatient setting, concurrent review or prior authorization.
- 5 years of a variety clinical experience required including acute care, home health, or long-term care.
- 5 years demonstrated ability to make thorough, independent decisions using clinical judgement.
- A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all noncompact states.
- Required to use a residential broadband service with internet speeds of at least 25 mbps/3mbps in order to ensure sufficient speed to adequately perform work duties.
- Some candidates may be eligible for partial reimbursement of the cost of residential broadband service.
