CVS Health Utilization Management Nurse Consultant RN in San Diego, California
Req ID: 73029BR
Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
Requires an RN with unrestricted active license.
Fundamental Components included but are not limited to:
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 coordination and administration of the utilization/benefit management function.
Qualifications Requirements and Preferences:
3+ years of clinical experience required
Post-acute experience preferred
RN with current unrestricted state licensure required
Managed Care experience preferred
Utilization management experience preferred
Additional Job Information:
Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.
Benefit eligibility may vary by position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.
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