Utilization Management Nurse Consultant Job at CVS Health (Work at Home)

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

New

Case Manager Registered Nurse

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

Location

United States , Work at Home

Salary:

54095.00 - 116760.00 USD / Year

CVS Health

Expiration Date

March 28, 2026

Requirements

Must have an active, current and unrestricted compact RN licensure in the state of residence
5 years clinical practice experience as an RN
2+ years’ experience in critical care
6+ months Case Management or Utilization Management experience
Must be able to work Monday through Friday 8:00am to 5:00pm in the time zone of residence
Must be able to obtain multi state RN licensures (expense paid for by organization)
Associate Degree in Nursing required

Job Responsibility

Telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness
Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration
Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues
Assessments consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality
Reviews prior claims to address potential impact on current case management and eligibility
Assessments include the member’s level of work capacity and related restrictions/limitations
Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality
Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management
Utilizes case management processes in compliance with regulatory and company policies and procedures

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