Utilization Management Nurse Consultant – MST/PST Zone
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Job Description
CVS Health UM Nurse Consultant reviewing medical necessity and coordinating care for U.S. members. Applying clinical criteria to make coverage determinations and support cost-effective healthcare.
Responsibilities:
- Review services for medical necessity and appropriate benefit use
- Facilitate efficient discharge planning
- Collaborate with providers and facilities to support members with complex needs
- Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits
- Collect and evaluate clinical information using clinical criteria, guidelines, policies, and judgment to make coverage determinations
- Communicate with providers and external partners to coordinate care and treatment plans
- Identify referrals to additional programs, services, or care solutions
- Promote quality care delivery and effective benefit utilization
- Serve as a resource to internal and external stakeholders on UM processes and clinical considerations
- Coordinate, document, and communicate utilization and benefit management activities while meeting state and federal requirements and turnaround times
Requirements:
- Active, unrestricted RN license
- 2+ years of acute hospital clinical experience
- Strong preference for medical-surgical, ICU, behavioral health, or another specialty area
- Strong clinical assessment and decision-making abilities
- Excellent organizational skills and ability to manage multiple priorities
- Ability to work independently and communicate effectively by phone
- Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls
- 1+ year of Utilization Review experience preferred
- 1+ year of Managed Care experience preferred
- Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) preferred
- Strong telephonic communication skills preferred
- Demonstrated sound judgment and ability to collaborate with diverse teams
- Associate Degree in Nursing (ADN) required
- Bachelor of Science in Nursing (BSN) preferred
- Availability for Monday–Friday, 8:00 AM–5:00 PM CST
- Weekends (12 per year) and holidays (1 minor and 1 major per year) required
- One 1:00 PM–7:00 PM shift per month, with day selection
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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