Concurrent Review Nurse

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time teleworker position in Oklahoma.

Working schedule is 8am – 5pm CST Monday-Friday with flexibility to work outside of the standard schedule based on business needs.

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization and benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for medical conditions based upon program focus.

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
• Identifies members who may benefit from care management programs and facilitates referral
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
• Coaches and trains junior colleagues in techniques, processes, and responsibilities.

Required Qualifications :

• Must reside in Oklahoma
• Registered Nurse (RN) with current unrestricted Oklahoma state licensure or compact state licensure.
• 3+ years of clinical practice experience in an inpatient setting
• 2+ years of experience as a Registered Nurse
• 2+ years of experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
• 1+ year(s) of discharge planning experience
• 1+ year(s) of Utilization Management experience
• Willing and able to provide on-call UM coverage for nights and weekends on a rotational schedule as required by the State regulatory agency.