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CVS Health UM Clinical Consultant in Illinois

Job Description

This is a full-time telework role, however, will require 10-25% travel once COVID restrictions are lifted.Schedule is Monday-Friday, standard business hours, with occasional flexibility required to work rotating weekends, as needed.Candidates in CST or EST time zones preferred.-Utilizes clinical skills to coordinate, document andcommunicate all aspects of the utilization/benefitmanagement program. Applies critical thinking andknowledge in clinically appropriate treatment, evidence basedcare and medical necessity criteria for appropriateutilization of services.-Consults and lends expertise to other internal andexternal constituents in the coordination and administrationof the utilization/benefit management function-Gathers clinical information and applies the appropriatemedical necessity criteria/guideline, policy, procedure andclinical judgment to render coveragedetermination/recommendation/discharge planning alongthe continuum of care-Utilizes clinical experience and skills in a collaborativeprocess to evaluate and facilitate appropriate healthcareservices/benefits for members including urgent oremergent interventions (such as triage / crisis support)-Coordinates/Communicates with providers and otherparties to facilitate optimal care/treatment-Identifies members who may benefit from caremanagement programs and facilitates referral-Identifies opportunities to promote quality effectiveness ofhealthcare services and benefit utilization

Required Qualifications

  • 3+ years of clinical practice experience in an inpatient setting required- 2+ years of Medicaid experience- 2+ years of utilization review experience- Concurrent review and/or prior authorization experience- RN with unrestricted state licensure required- Willingness to obtain additional state licenses

Preferred Qualifications

  • RN in a compact state preferred- Discharge planning experience


  • RN with unrestricted state licensure required- Associate's degree required- Bachelor's degree preferred

Business Overview

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.