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UM Nurse Consultant

Aetna Inc.

This is a Full-time position in Carlsbad, CA posted May 9, 2022.

Job Description This Utilization Management (UM) Nurse Consultant role is currently work from home; however, the employee may have to physically report to the High Point, North Carolina office once COVID-19 restrictions are lifted.

The office is located at 4050 Piedmont Parkway, High Point, North Carolina.

Work from home opportunities may be available after 12-18 months of employment, determined by business need and employee competency.

Normal Working Hours: 8:30am-5:00pm EST per the need of the department.

There is a late shift requirement until 9:00pm EST approximately 2-3 times per year.

Holiday rotation per the need of the department (typically 1 holiday per year).

There is no travel expected with this position.

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times.

This includes reviewing written clinical records.

The UM Nurse Consultant job duties include (not all encompassing): Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Utilizes 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 Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Required Qualifications RN with active and unrestricted state licensure 3 years of acute hospital clinical experience as an RN Must be able to commute to the High Point, NC office.

COVID Requirements COVID-19 Vaccination Requirement CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment.

Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications 1 years’ experience Utilization Review 1 years’ experience Managed Care Strong telephonic communication skills 1 years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook) BSN Education Associates Degree in Nursing Business Overview 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.

We strive to promote and sustain a culture of diversity, inclusion and belonging every day.

CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services.

We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.