Utilization Management Nurse Consultant Job at CVS Health

Appeals Nurse Consultant

This is a full-time telework position. Hours for this role are Monday-Friday 8a-...

Location

United States

Salary:

Not provided

CVS Health

Expiration Date

Until further notice

Requirements

Must have active and unrestricted RN licensure in state of residence
3+ years clinical experience

Job Responsibility

Responsible for the review and resolution of clinical appeals
Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues
Independently coordinates the clinical resolution with internal/external clinician support as required

Fulltime

Case Manager, Registered Nurse

Remote case manager position working intensely as a telephonic case manager with...

Location

United States , Remote

Salary:

54095.00 - 155538.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

5+ years’ experience as a Registered Nurse
1+ year of experience in a hospital setting
Active, unrestricted RN license in state of residence
Willingness to receive multi-state/compact privileges
1+ years' experience documenting electronically using a keyboard
1+ years' current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience

Job Responsibility

Work as a telephonic case manager with patients and their care team
Application and/or interpretation of applicable criteria and clinical guidelines
Assess benefits and/or member's needs to ensure appropriate administration of benefits
Incorporate strategies designed to reduce risk factors and barriers
Address complex health and social indicators which impact care planning
Consult with supervisor and others in overcoming barriers
Utilize case management processes in compliance with regulatory requirements
Utilize motivational interviewing skills for member engagement
Identify and escalate member's needs appropriately
Actively reach out to members to collaborate/guide their care

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules

Fulltime

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

New

Utilization Management Nurse Consultant

We’re building a world of health around every individual — shaping a more connec...

Location

United States

Salary:

26.01 - 68.55 USD / Hour

CVS Health

Expiration Date

March 04, 2026

Requirements

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Must have active current and unrestricted RN licensure in state of residence
Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours
Associates Degree required
Proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written

Job Responsibility

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

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance

Fulltime

Nursing Quality & Practice Manager

This position primarily involves daytime hours on weekdays, with occasional trav...

Location

United States , Oak Brook

Salary:

51.05 - 76.60 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse license issued by the state in which the team member practices
Master's Degree in Nursing or related field
Typically requires 7 years of experience in nursing practice or project management experience in a healthcare environment
Expert in applying science to nursing practice
Demonstrated knowledge of change management methods
Knowledge of statistical methods, data analysis and presentation tactics
Competent in process improvement methodologies
Ability to manage multiple priorities
Proven critical thinking skills
Acts as a responsible steward of resources

Job Responsibility

Supports System Practice Excellence Councils and Shared Governance Specialty Practice Groups to achieve prioritized system nursing outcomes by assisting and mentoring synthesis of research, data and evidence and use of improvement tools and methods including improvement project plans
Assists teams to identify and achieve measurable goals
Uses data and evidence to determine priorities for nursing intervention
Informs and collaborates with stakeholder teams across AAH
Critically analyzes results and leads and/or supports continuous process improvement
Conducts synthesis of evidence for strategic projects
Promotes research and evidence-based practice through the review, interpretation, and implementation of research findings
Supports process improvement and change management utilizing proven tools and processes
Leads/supports/facilitates teams to set goals, identify clear accountabilities and timelines, and develop effective communication and engagement strategies
Serves as nursing practice consultant on interprofessional teams maintaining a systems perspective on proposed changes for both patient populations, nursing practice, and system outcomes

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Utilization Management Nurse Consultant

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Work at Home

Salary:

29.10 - 62.32 USD / Hour

CVS Health

Expiration Date

March 28, 2026

Requirements

Must have an active and unrestricted RN license
2+ years of recent acute hospital clinical experience as an RN (recent defined as in the past 10 years)
Utilization Review experience
Managed Care background
Strong telephonic communication skills
BSN
Experience with all types of Microsoft Office including PowerPoint, Excel, and Word
Associates Degree in Nursing/BSN preferred

Job Responsibility

Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program
Ensure 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
Review written clinical records
Review 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

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance

Fulltime

New

Registered Nurse Case Manager (Maternal/Child)

Full time 2nd shift RN, Case Manager - This would be a position for our Maternal...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Bachelor's degree in nursing or associate degree in nursing
Two (2) years of nursing or case management experience
For NICU – Three (3) years of NICU nursing experience
Current RN licensure permitting work in state of Arizona
Basic life support (BLS) required
Some departments may also require current CPR instructor certification, Neonatal Resuscitation Provider (NRP) certification
Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care
Skill in evaluating cases and determining appropriate care and status
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations
Ability to write reports, business correspondence and collaborate with case management leadership on the creation and update of necessary standards of work

Job Responsibility

Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge
Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation
Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members
Identifies and resolves barriers that hinder effective patient care
Improves quality and completeness of documentation
Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process
Assesses, creates, implements evaluates, and modifies timely discharge plans
Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families
Enters nursing orders for their assigned patient caseload related to discharge planning and transitional care needs
Assists patients and families in making difficult decisions, while honoring their preferences and values

Fulltime

Rn case manager

Under the general supervision of the Case Management Manager acts as a patient a...

Location

United States , Weymouth

Salary:

59.42 - 86.20 USD / Hour

South Shore Health

Expiration Date

March 12, 2026

Requirements

Registered Nurse, Bachelors prepared strongly preferred
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
RN - Registered Nurse license
ACM-Accredited Case Manager or CCM-Certified Case Manager within two years of hire
Demonstrated skills in: negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management and ability to multitask in high stress environment
Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis
Knowledge of utilization management as it relates to third party payers
Knowledge of post-acute care community resources
Experience with Managed Care preferred

Job Responsibility

Acts as a patient advocate/Case Manager
Coordinates, negotiates, procures services and resources for, and manages the care of complex patients
Applies review criteria to determine medical necessity for admission and continued stay
Provides clinically-based case management, discharge planning and care coordination
Reviews medical record of all observation and inpatient admissions and continued stays
Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining medical necessity
Identifies cases that fail to meet criteria and refers for secondary review
Contacts attending physicians on cases lacking adequate documentation
Contacts attending physician to notify of decision to issue notice of non-coverage
Informs patient and/or next of kin when insurance coverage must be terminated

Parttime

Utilization Management Nurse Consultant

CVS Health

Location:
United States

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
March 04, 2026

Expiration:
March 06, 2026

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