Medicare Clinical Predetermination Nurse

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 colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do.

Job Summary: As a Medicare Clinical Predetermination Nurse, you will utilise 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.

Responsibilities:

• Gather clinical information and apply clinical criteria/guidelines, policies, procedures and clinical judgment to render coverage determinations/recommendations along the continuum of care.
• Communicate with providers and other parties to facilitate care/treatment.
• Identify members for referral opportunities to integrate with other products, services and/or programs.
• Identify opportunities to promote quality effectiveness of Healthcare Services and benefit utilisation.
• Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilisation/benefit management function.

Requirements:

• 3+ years of experience as a Registered Nurse.
• Active current and unrestricted RN licensure in state of residence.
• 1+ years of Med/Surg experience.
• 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel).
• Must be willing and able to work Monday through Friday, 9:00am to 5:30pm eastern or central time with occasional holiday rotation.

Preferred Qualifications:

• Prior Authorisation or Utilisation Management experience.
• Managed care experience.
• Experience using MedCompass.
• Ambulatory surgery experience.

Education:

• Associate's degree required.
• BSN preferred.

Work from Home Requirements:

• Direct/hardwired internet connection to a modem/router within 7 feet of computer.
• Minimum download speed of 25 mbs download and 3 mbs upload.
• Quiet, secure and private designated home virtual work location.

Technical and Logistical Requirements:

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications.
• Systems Access & Security: Ability to Log in to secure systems, lock a computer screen when unattended, manage strong passwords, and recognise suspicious emails or links.

Benefits:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.

Salary Range: $29.10 - $62.32

Anticipated Weekly Hours: 40

Time Type: Full time