Utilization Management Nurse Consultant - Medical Review (Remote)

CVS Health

76d • $29 - $62

About The Position

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. This position is a Utilization Management (UM) Nurse Consultant specializing in Medical Review, where you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.

Requirements

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges.
• Minimum 3 years of clinical experience.
• 5 years demonstrated to make thorough independent decisions using clinical judgement.
• 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.
• 1+ Year of Utilization Review Management and/or Medical Management experience.
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

Nice To Haves

• Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity.
• MCG Milliman, InterQual, CPB or other criteria guideline application experience is preferred.

Responsibilities

• Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.
• Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.
• Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines.
• Authorizes procedures/services or initiates a Medical Director referral as needed.
• Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.
• Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.
• Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.
• Must be able to work independently without personal distractions to meet quality and metric expectations.
• Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

Benefits

• Affordable medical plan options.
• 401(k) plan (including matching company contributions).
• Employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Paid time off.
• Flexible work schedules.
• Family leave.
• Dependent care resources.
• Colleague assistance programs.
• Tuition assistance.
• Retiree medical access.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree