Job Information
CVS Health Utilization Management Nurse Consultant in Frankfort, Kentucky
At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services.
Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making.
Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.
Required Qualifications
Working knowledge of problem solving and decision making skills.
Working knowledge of medical terminology.
Working knowledge of digital literacy skills.
Ability to deal tactfully with customers and community.
Ability to handle sensitive information ethically and responsibly.
Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients
RN License
Preferred Qualifications
Working knowledge of problem solving and decision making skills.
Working knowledge of medical terminology.
Working knowledge of digital literacy skills.
Ability to deal tactfully with customers and community.
Ability to handle sensitive information ethically and responsibly.
Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients
Education:
Bachelor's degree preferred/specialized training/relevant professional qualification.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$26.01 - $68.55
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 04/29/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.