Utilization Review Nurse
-Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.
-Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.
-Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.
-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
-RN with current unrestricted state licensure
-3+ years of clinical experience
-3+ years of Post-Acute Care experience
-Managed Care experience
-Utilization Management experience
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.