Utilization Management Clinical Reviewer

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 Utilize your clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.

Key Responsibilities

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

Requirements

• Registered Nurse with active current and unrestricted RN licensure in state of residence.
• 3+ years of experience as a Registered Nurse, 1+ years of clinical experience in acute or post-acute setting, and 1+ years of Utilization Management/Care Management Experience.
• Effective verbal and written communication skills.
• Proficiency with computer skills, including navigating multiple systems and keyboarding.
• Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment.

Benefits This full-time position is eligible for a comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources.

Pay Range $29.10 - $62.32 per hour