Utilization Management Nurse Consultant

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 passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Schedule: This is an Alternative Work Schedule weekend position. The role requires coverage of both Saturday and Sunday each week. Scheduling options may include four 10-hour shifts, five 8-hour shifts, three 12-hour shifts, or other approved configurations that meet operational needs. Specific schedules will be determined in collaboration with management to ensure adequate weekend coverage. Position 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 the appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations and recommendations along the continuum of care. * 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 other internal and external constituents in the coordination and administration of the utilization/benefit management function. * Meet set productivity and quality expectations as established by UMNC. Required Skills and Abilities: * Effective verbal and written communication skills. * Proficiency with computer skills, including navigating multiple systems and...