Utilization Management Clinical Consultant

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Oversee, document, and communicate all facets of the utilization/benefit management program.

• Utilize critical thinking, evidence-based care, and medical necessity criteria to assess suitable service utilization.

• Collaborate with internal and external stakeholders regarding utilization/benefit management.

• Collect clinical information and apply medical necessity criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations, recommendations, and discharge planning.

• Assess and facilitate the appropriate healthcare services and benefits for members.

• Coordinate and communicate with providers and other parties to ensure optimal care and treatment.

• Identify members who may gain from care management or post-discharge programs and facilitate referrals.

• Recognize opportunities to enhance quality and effective healthcare services and benefit utilization.

• Manage cases within a Skilled Nursing Facility setting.

• Perform retrospective reviews and analyze assessed claims.

⛳️ Requirements

• Active, unrestricted Arizona RN license or a compact license that encompasses Arizona.

• 3+ years of clinical practice experience, such as in a hospital, SNF, home health, or ambulatory care setting.

• Associate's degree in nursing (RN) is mandatory.

• Clinical experience in ER, ICU, or Critical Care is preferred.

• Experience in Managed Care/Utilization Management is favored.

• Capability to make comprehensive independent decisions utilizing clinical judgment.

• Proficient in the use of computers, telephones, equipment, and clinical documentation systems.

• Familiarity with claims review processes.

• A dedicated workspace that is free from interruptions.

• Arrangements for dependents during work hours must be separate; continuous care responsibilities during shift times are not allowed.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Resources that support physical, emotional, and financial well-being.

• Occasional travel opportunities for staff events.