Utilization Management Nurse Consultant

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose : Bringing our heart to every moment of your health.

This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Must reside within 45 miles to office location in High Point, NC.

Precertification Nurse Case Manager is responsible for telephonically 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.

Services strategies, policies and programs are comprised of network management and clinical coverage policies.

What is A1A?

Aetna One Advocate is Aetna's premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members.

The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services.

Our mission is to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members' needs and create behavior change.

Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today.

We are health care innovators.

Fundamentals :

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 take into account 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.

Required Qualifications :

• Must have active, current and unrestricted compact RN state licensure
• Must reside within 45 miles to office location in High Point, NC
• 3+ years of clinical practice experience required
• Must be able to work Monday through Friday 8 : 00 AM to 4 : 30 PM, EST with evening rotation required about 2 times a month until 8pm, EST.
• This position is work from home, however may include on site work requirements from time to time including; team meetings, colleague trainings, customer visits, performance related issues, and other business needs.
• 2+ years of experience using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications :

Ability to organize, multitask, prioritize and work in a fast pace environment.

Education :

Associates degree required

BSN preferred

Pay Range

The typical pay range for this role is :

$26.01 - $56.13

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com / benefits

We anticipate the application window for this opening will close on : 05 / 27 / 2024