Utilization Management Nurse Consultant - Fully Remote

at CVS Health in Montpelier, Vermont, United States Job Description We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time. Position Summary CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to) + Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. + Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. + Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. + 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. + 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, service To view full details and how to apply, please login or create a Job Seeker account