Cebu USRNs! *100K Signing Bonus

Utilization Management Nurse Consultant

Family Summary/Mission

Facilitate the delivery of appropriate benefits and/or healthcare information which promotes cost effective outcomes for the customers.

Position Summary/Mission

Responsible for the review and evaluation of clinical information and documentation.Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.Independently coordinates the clinical resolution with internal/external clinician support as required.Requires an RN with unrestricted active license.

Fundamental Components & Physical Requirements (include but are not limited to)

Note: * denotes essential functions

Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.Data gathering requires navigation through multiple system applications.Staff may be required to contact the providers of record, vendors, or internal CVS departments to obtain additional information.evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.Condenses complex information into a clear and precise clinical picture while working independently.Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Background/Experience Desired

3-5 years Clinical ExperiencePractical experience in areas of acute care, emergency room, cardiology, radiology, etc.Managed Care experience preferred

Education and Certification Requirements

B.S. Nursing GraduateUS Registered Nurse with current unrestricted state licensure

Additional Information (situational competencies, skills, work location requirements, etc.)

Position requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentSedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Typical office working environment with productivity and quality expectations