CVS Health is hiring a Utilization Management Clinical Consultant to join Mercy Care. In this remote role, you will coordinate and manage all aspects of the utilization/benefit management program for Arizona's vulnerable populations. Your clinical expertise will be essential for handling hospital cases, conducting retrospective reviews, and analyzing claims.
What You'll Do
- Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
- Apply critical thinking and clinical knowledge for appropriate utilization of services using evidence-based care and medical necessity criteria.
- Consult with internal and external constituents on utilization/benefit management functions.
- Gather clinical information to render coverage determinations, recommendations, and discharge planning.
- Evaluate and facilitate appropriate healthcare services and benefits for members using a collaborative process.
- 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 quality effectiveness of healthcare services and benefit utilization.
What We're Looking For
- Active, unrestricted Arizona RN license or a compact license that includes Arizona.
- 3+ years of clinical practice experience, such as in a hospital setting, home health, or ambulatory care.
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, computer, and clinical documentation systems.
Benefits & Compensation
- Compensation range: $29.10 - $62.32 per hour.
- Affordable medical plan options.
- 401(k) plan with matching company contributions.
- Employee stock purchase plan.
- No-cost programs including wellness screenings, tobacco cessation, weight management, 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 full-time, remote position for candidates located in Arizona.
CVS Health is passionate about transforming health care, caring for people where, when and how they choose. We are committed to fostering a workplace where every colleague feels valued and that they belong.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
