CVS Health is hiring a Utilization Management Clinical Consultant to join our team. This remote role based in Arizona focuses on handling cases within a hospital setting and managing back-end responsibilities like retrospective reviews and claims analysis. You'll be part of a company passionate about transforming health care in a way that's more connected, convenient, and compassionate.
What You'll Do
- Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization and benefit management program.
- Apply critical thinking and clinical knowledge to evaluate treatment, evidence-based care, and medical necessity for appropriate service utilization.
- Gather clinical information and apply medical necessity criteria, policy, procedure, and clinical judgment to render coverage determinations and discharge planning.
- Use clinical experience in a collaborative process to evaluate and facilitate appropriate healthcare services and benefits for members.
- Coordinate and communicate with providers and other parties to facilitate optimal care and treatment.
- Identify members who may benefit from care management or post-discharge programs and facilitate referrals.
- Identify opportunities to promote the quality and effectiveness of healthcare services and benefit utilization.
- Consult and lend expertise to other internal and external constituents in the coordination and administration of utilization management.
What We're Looking For
- Active, unrestricted Arizona RN license or a compact license that includes Arizona.
- 3+ years of clinical practice experience, for example in a hospital setting, home health, or ambulatory care.
- Associate's degree in nursing (RN).
Nice to Have
- Clinical experience in ER, ICU, or Critical Care.
- Managed Care or Utilization Management experience.
- Experience with Claims Review processes.
- Demonstrated ability to make thorough independent decisions using clinical judgement.
- Proficient use of equipment, including phone and computer, and clinical documentation systems.
- BSN degree.
Technical Stack
- Clinical documentation systems
Benefits & Compensation
- Compensation: $29.10 - $62.32 per hour.
- Affordable medical plan options.
- 401(k) plan with matching company contributions.
- Employee stock purchase plan.
- No-cost programs for all colleagues, including wellness screenings, tobacco cessation, weight management, confidential counseling, and financial coaching.
- Paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, and retiree medical access.
Work Mode
This is a remote position requiring the candidate to be located within Arizona.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
