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At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryUtilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.<ul> <li>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.</li> <li> 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</li> <li>Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs</li> <li>Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization</li> <li>Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.</li> <li>Typical office working environment with productivity and quality expectations.</li> <li>Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.</li> <li>Sedentary work involving periods of sitting, talking, listening.</li> <li>Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.</li> <li>Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.</li> <li>Effective communication skills, both verbal and written</li> </ul>Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence- Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management- Preference for those residing in ET, CT zones EducationAssociates Degree requiredBSN preferredAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$29.10 - $62.32This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 06/16/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CVSHealth

Utilization Management Nurse Consultant

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position Summary CVS Health, a Fortune 6 company, has an outstanding opportunity for a Medical Director (Medical Affairs).This is a remote based, work from home opportunity. The Medical Affairs department provides clinical business support to the entire enterprise and provides clinical oversight and mentorship for CVS Health clinical programs, PBM Clinical Quality activities, consultative support to the P&amp;T process, formulary development, drug information services and pipeline activities, and provision of clinical leadership to various internal departments (e.g., specialty pharmacy services, clinical product development, Enterprise Analytics, Compliance, Legal, Accreditation) and clients. The Medical Director (Medical Affairs) will report into the Medical Affairs Department and is responsible for clinical support and consultative activities across the PBM. In this role you may provide consultative clinical support to Account Management in support of Key Clients as assigned. The Medical Director transacts Utilization Management UM activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to CVS Health coverage policies. Medical Directors at CVS Health are encouraged to model the highest levels of clinical integrity, knowledge and cross functional thinking and decision making. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a partner across the enterprise’s decisions and planning. – Each Director is responsible for providing oversight of a portion of CVS Health's clinical programs and commercial client program support. Will share in reviews of utilization management (PA) criteria and clinical policy revisions/reviews. – Directors will spend a portion of most days completing assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate. – Medical Directors will participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions. If specifically assigned to one business segment (i.e., Medicare clients), each director will become sufficiently skilled in various UM programs to support other segments (including commercial and Medicaid) on evening and weekend coverage. –In this role you'll perform a share of special clinical investigations and research as requested by the Senior Medical Director, Medical Affairs. These projects can include brief reviews of published literature around specific pharmaceutical questions or more in-depth projects requiring collaboration with pharmacists within Medical Affairs and in business units outside of the Department. CVS Health, a Fortune 4 company, has an outstanding opportunity for a Medical Director (Medical Affairs). Required Qualifications * Family Medicine or Internal Medicine Board Certification.* Minimum of 5 years clinical experience in direct patient care. * 2 or more years proven experience in clinical outcomes, with a solid understanding of medical statistics, regulatory agencies, and analytic programs * Unrestricted license to practice medicine in the state in which the candidate is located. Preferred Qualifications * Combination of five years of management and/or clinical experience in a managed care environment and health administration, including adequate clinical experience in direct patient care and working with professionals at different levels as a teammate (e.g., RNs, PharmDs, etc.). * ABMS or AOA Board Certified in a recognized medical specialty, preferably in a Primary Care field (Internal medicine, Family Medicine) * Master’s Degree in Public Health Administration or MBA preferred, UM/QA certification desired * Proficiency in MS Office Suite Education * Must be graduate of an accredited Medical School and Residency Program * Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia * Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employmentPay RangeThe typical pay range for this role is:$174,070.00 - $374,920.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 06/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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