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Weekday Cvs Utilization Management Nurse Jobs in Michigan

OpTech LLC

RN Utilization Management

Detroit, MI · On-site

Detroit, Michigan Registered Nurse (RN) Contract We are seeing a Michigan RN Utilization Manager. This is a 100% remote position in Michigan. Perform prospective, concurrent and retrospective review ...

McLaren

Registered Nurse Care Manager PRN

Lapeer, MI · On-site

Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home ... Experience in utilization management/case management, critical care, or patient outcomes/quality ...

McLaren

Registered Nurse Care Manager

Petoskey, MI · On-site

Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home ... Experience in utilization management/case management, critical care, or patient outcomes/quality ...

McLaren

Registered Nurse Care Manager

Mount Clemens, MI · On-site

Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home ... Experience in utilization management/case management, critical care, or patient outcomes/quality ...

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Weekday Cvs Utilization Management Nurse information

What is a Weekday CVS Utilization Management Nurse?

A Weekday CVS Utilization Management Nurse is a registered nurse who works for CVS Health, focusing on evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. This role involves reviewing patient cases, coordinating with healthcare providers, and ensuring that treatments and services meet established guidelines and insurance requirements. These nurses typically work regular weekday hours, rather than nights or weekends. They play a key role in helping patients receive appropriate care while also managing healthcare costs for the organization.

What are the key skills and qualifications needed to thrive as a Weekday CVS Utilization Management Nurse?

To thrive as a Weekday CVS Utilization Management Nurse, you need a valid RN license, strong clinical assessment skills, and experience in case management or utilization review. Familiarity with healthcare management software, insurance guidelines, and medical coding systems such as ICD-10 is typically required. Exceptional critical thinking, attention to detail, and effective communication help nurses advocate for appropriate patient care while collaborating with providers and payers. These skills ensure proper resource utilization, regulatory compliance, and optimal patient outcomes in a managed care setting.

How does a Weekday CVS Utilization Management Nurse typically collaborate with physicians and case managers?

As a Weekday CVS Utilization Management Nurse, you will regularly interact with physicians and case managers to review patient care plans and ensure appropriate resource utilization. This role involves evaluating medical records, discussing treatment options, and providing clinical recommendations to support cost-effective, quality care. Effective communication and teamwork are essential, as you’ll serve as a bridge between clinical staff, patients, and administrative teams to coordinate authorizations and resolve coverage questions.

What is the difference between Weekday Cvs Utilization Management Nurse vs Weekend Cvs Utilization Management Nurse?

AspectWeekday Cvs Utilization Management NurseWeekend Cvs Utilization Management Nurse
Work ScheduleMonday to Friday, standard business hoursWeekend shifts, typically Saturday and Sunday
CertificationsRN license, utilization review certification often preferredRN license, utilization review certification often preferred
Work EnvironmentOffice-based, healthcare setting, insurance companyOffice-based, healthcare setting, insurance company
Job ResponsibilitiesReview medical necessity, authorize services, coordinate careReview medical necessity, authorize services, coordinate care

The main difference between Weekday Cvs Utilization Management Nurse and Weekend Cvs Utilization Management Nurse lies in their work schedule. Both roles require similar certifications, responsibilities, and work environments, but the weekday nurse works during standard business hours, while the weekend nurse covers weekend shifts. Both positions are essential for continuous patient care and insurance operations.

What are the most commonly searched types of Cvs Utilization Management Nurse jobs in Michigan?

The most popular types of Cvs Utilization Management Nurse jobs in Michigan are:

What cities in Michigan are hiring for Weekday Cvs Utilization Management Nurse jobs?

Cities in Michigan with the most Weekday Cvs Utilization Management Nurse job openings:

Weekday Cvs Utilization Management Nurse jobs near you

RN Utilization Management

OpTech LLC

Detroit, MI • On-site

Full-time

Retirement

Posted 16 days ago

Job description

Detroit, Michigan
Registered Nurse (RN)
Contract
We are seeing a Michigan RN Utilization Manager. This is a 100% remote position in Michigan.
Job Description:
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.
EDUCATION AND EXPERIENCE:
  • Registered Nurse unrestricted/current Michigan RN license
  • 2 + yr clinical experience - acute care
  • Utilization Management experience/role
  • Technical - MS Office, Type 35+ WPM, Dual monitors, multiple systems
  • 1 yr health insurance plan experience or managed care environment preferred .
  • Bachelor's degree in nursing, allied health, business, or related field preferred .
  • Certification in Case Management preferred

ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
2. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
3. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
4. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
5. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
6. Identify and document quality of care issues; resolve or route to appropriate area for resolution.
7. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
8. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
9. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
10. Other duties may be assigned based on designated department assignment.
Why work with us? We are a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work with us you'll have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! We are an EOE, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. https://www.optechus.com/eeo_self_identification/

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