Utilization Management Nurse Consultant – Behavioral Health
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Job Description
Behavioral health utilization nurse reviewing inpatient and outpatient care for CVS Health’s managed-care members. Applying clinical criteria, authorizing services, and coordinating provider escalations remotely.
Responsibilities:
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to inpatient and outpatient treatment and services requiring precertification
- Use specific criteria to authorize procedures and services or initiate Medical Director referrals as needed
- Collect and review clinical information from providers
- Collaborate with providers and escalate cases when needed
- Navigate multiple systems and maintain accurate documentation
- Provide utilization management review in a fast-paced, computer-based environment
- Perform sedentary desk and telephone work involving sitting, talking, listening, and computer use
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
- Commitment to attend mandatory 3-week training, Monday–Friday, 8:30am–5:00pm EST, with 100% participation
- Ability to work occasional on-call rotational coverage on weekends and some rotational on-call holiday coverage
- Associate's degree in nursing (RN) required
- Proficiency with computer skills and navigating multiple systems
- Dedicated workspace free of interruptions
- Separate care arrangements for dependents during work hours
- Preferred: 1+ years Managed Care (MCO) experience
- Preferred: 1+ year experience in a high-volume clinical call center environment
- Preferred: Remote work experience
- BSN preferred
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 eligibility
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