Utilization Management Nurse Consultant (Prior Authorization)

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.

Position Summary

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the and administration of the utilization/benefit management function

Required Qualifications

• 3+ years of experience as an RN in a clinical setting (all clinical areas considered: Home Health, Med/Surge, Telemetry, ICU, NICU, Long term care, orthopedics, and more)
• Must have active current and unrestricted RN licensure in state of residence
• Must be able to work Monday through Friday, 8am to 5pm in time zone of residency with flexibility to work rotating holiday and weekends per business needs
• MS Office suites experience