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Commission Cvs Health Utilization Management information

What is a Commission CVS Health Utilization Management role?

A Commission CVS Health Utilization Management role involves evaluating and coordinating healthcare services to ensure patients receive appropriate, cost-effective care. These professionals assess medical necessity, review authorization requests, and work closely with providers, patients, and insurance plans. Their goal is to optimize healthcare resources while maintaining quality care standards, often by applying clinical guidelines and industry regulations. The role typically requires a background in healthcare, nursing, or pharmacy and strong analytical and communication skills.

What are the key skills and qualifications needed to thrive as a CVS Health Utilization Management professional, and why are they important?

To thrive as a CVS Health Utilization Management professional, you need a background in healthcare, strong analytical skills, and typically a valid RN license or relevant clinical degree. Familiarity with utilization review systems, electronic health records (EHR), and regulatory guidelines such as Medicare and Medicaid is essential. Strong communication, attention to detail, and critical thinking are standout soft skills for this role. These skills are vital to ensure appropriate, cost-effective patient care and compliance with healthcare policies.

What are the typical challenges faced by a Commission CVS Health Utilization Management professional when reviewing complex cases?

Commission CVS Health Utilization Management professionals often encounter challenges such as interpreting nuanced medical information, staying updated with evolving clinical guidelines, and balancing cost-effectiveness with patient care needs. Complex cases may require collaboration with physicians, nurses, and pharmacists, as well as thorough documentation to ensure compliance with regulations. Managing a high volume of cases while maintaining accuracy and timeliness is also a common aspect of the role.

What is the difference between Commission Cvs Health Utilization Management vs Utilization Review Nurse?

AspectCommission Cvs Health Utilization ManagementUtilization Review Nurse
CertificationsCPUR, CCM, or relevant healthcare certificationsRN license, possibly with certifications like CURN
Work EnvironmentInsurance companies, healthcare providers, or managed care organizationsHospitals, clinics, or insurance companies
Primary ResponsibilitiesReviewing medical necessity, authorizing services, managing utilization dataAssessing patient records, determining care appropriateness, authorizing treatments

Both roles focus on evaluating healthcare services, but Commission Cvs Health Utilization Management often involves broader program oversight and data analysis, while Utilization Review Nurses primarily conduct clinical assessments. Understanding these differences helps job seekers identify the right career path in healthcare utilization roles.

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What job categories do people searching Commission Cvs Health Utilization Management jobs in Indiana look for? The top searched job categories for Commission Cvs Health Utilization Management jobs in Indiana are:
What cities in Indiana are hiring for Commission Cvs Health Utilization Management jobs? Cities in Indiana with the most Commission Cvs Health Utilization Management job openings:
Commission Cvs Health Utilization Management jobs near you

Utilization Management Nurse

SIHO HOLDING INC

Columbus, IN • On-site

Other

This job post has expired today. Applications are no longer accepted.

Job description

Job Title:  Utilization Management Nurse
Reports To:  Manager of Utilization Management
Employment Type:  Full-Time, Exempt

Brief Description of Duties:    
This position is reserved for a licensed Registered Nurse who will perform the Utilization Management (UM) services for SIHO (and affiliated business lines’) members. This individual’s primary role is to ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines. By performing review of services prospectively, retrospectively, and throughout the episode of care, the UM nurse will make coverage determinations influencing how services are allocated to SIHO’s various member populations.  A candidate’s ability to perform quality reviews within strict efficiency standards is required for this position.  Key responsibilities are as follows:

  • Pre-service, concurrent, and post-service review for medical necessity of health care services utilizing enrollee medical records and established guidelines set by SIHO and/or state and federal (CMS) guidelines
  • Interaction with the member, health care provider, and/or other care team members to complete reviews in most time-efficient manner
  • Interaction with the SIHO Medical Director or external Medical Reviewers as needed to ensure proper medical necessity decisions are made in a timely manner
  • Appropriate documentation of the entire review process utilizing the established documentation system and desk procedures to guarantee accurate reporting metrics and data integrity
  • Complete case review and manage turnaround times to assure determinations are rendered within the contractual and regulatory turnaround times established by SIHO and CMS
  • Assist in problem resolution and provide guidance to members of the team and cohorts
  • Interpret and abide by organizational policies and procedures; review work regularly to ensure that policies and guidelines are appropriately applied
  • Act as a clinical resource to the department and other organization members for services pertaining to medical management, utilization review, and medical necessity 
  • Act and perform within the scope of professional nursing practice; display responsibility in supporting and participating in department strategies and efforts focused on quality improvement
  • Responsible for the early identification and assessment of members for inclusion in disease management or care management programs
  • Assist in the identification and reporting of Potential Quality of Care concerns and Fraud, Waste and Abuse incidents
  • Work as an interdisciplinary team member within Medical Management for all lines of business and commercial group plans
  • Show effective prioritization, efficiency and accuracy of work product in alignment with department goals.

Minimum Skills Requirement:

  • Registered Nurse with current, unrestricted license in primary state of employment (position may require additional licensing in other states as necessary)
  • Previous UM or Health Plan experience highly preferred
  • Desire to work in a fast-paced environment with focus on efficiency and attention to detail while maintaining quality
  • Self-directed organizational and prioritization skills, and independent time management skills required
  • Sound clinical background with experience in the clinical field
  • Excellent verbal and written communication skills
  • Microsoft Office Experience: Outlook, Word, Excel

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