Utilization Management Nurse Consultant – Behavioral Health
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Job Description
Utilization Management Nurse reviewing behavioral health inpatient and outpatient services for CVS Health’s medical management organization. Applying clinical criteria, authorizing care, and escalating cases.
Responsibilities:
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to inpatient and outpatient services requiring precertification
- Use utilization management criteria to authorize procedures and services or initiate Medical Director referrals
- Collaborate with providers and authorize care
- Escalate cases when needed
- Navigate multiple systems and maintain accurate documentation
- Collect and review clinical information from providers by telephone and computer
- Provide occasional rotational weekend on-call and holiday on-call coverage
Requirements:
- Active unrestricted state Registered Nurse licensure in state of residence required
- 3+ years of acute behavioral health and/or substance abuse clinical nursing experience
- 1+ year of concurrent review or prior authorization preferably in Behavioral Health and Substance Abuse
- Mandatory 3-week training, Monday–Friday, 8:30am–5:00pm EST, with 100% participation
- Associate's degree in nursing (RN) required
- Ability to work occasional on-call rotational coverage on weekends and some rotational on-call holiday coverage
- Proficiency with computer skills and navigating multiple systems
- Dedicated workspace free of interruptions
- Dependents must have separate care arrangements during work hours
- Preferred: 1+ years Managed Care (MCO) experience
- Preferred: 1+ year demonstrated experience working in a high-volume clinical call center environment
- Preferred: Remote work experience
Benefits:
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- CVS Health bonus, commission or short-term incentive program in addition to base pay
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