Utilization Management Nurse Consultant

CVS Health • New York, MA

2d • $26 - $69 • Remote

About The Position

The Utilization Management Nurse Consultant uses clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options that facilitate appropriate healthcare services and benefits for members. The role gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations across the continuum of care.

The consultant communicates with providers and other parties to facilitate care and treatment, identifies members for referral to other products, services, or programs, and identifies opportunities to promote quality and effective healthcare services and benefit utilization. The role also provides expertise to internal and external constituents in coordinating and administering utilization and benefit management.

Utilization Management operates 24/7, so schedules may include weekends, holidays, and evening hours. This is a work-from-home position with requirements for a secure, private, quiet workspace and a direct wired internet connection meeting the stated speed requirements. Employees must work from the state and city where they currently live. CVS Health provides computer equipment, but employees provide their own workspace furniture. The role involves using multiple applications and monitors, digital communication and collaboration tools, and secure systems, and requires handling common technical issues.

Requirements

• 3–5 years of Med/Surg experience.
• At least 3 years of experience as an RN.
• At least 1 year of inpatient hospital experience.
• Active, current, and unrestricted RN licensure in the state of residence.
• Ability to work in multiple IT platforms and systems.
• At least 1 year of experience with Microsoft Office applications, including Outlook, Teams, and Excel.
• Associate degree required.
• Ability to meet work-from-home requirements, including direct wired internet with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
• Ability to maintain a quiet, secure, private, and distraction-free designated home workspace compliant with company and HIPAA guidelines.
• Ability to use multiple monitors and applications, communicate through digital channels, access secure systems, follow security practices, and troubleshoot common technical issues.
• Openness to learning new skills as the workplace environment evolves.

Nice To Haves

• Experience with Medicare/Medicaid populations.
• MCG experience.
• Managed care experience.
• UM certification.
• MedCompass experience.
• At least 1 year of inpatient utilization experience.
• BSN.

Responsibilities

• Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.
• Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations across the continuum of care.
• Communicate with providers and other parties to facilitate care and treatment.
• Identify members for referral opportunities to other products, services, and programs.
• Identify opportunities to promote quality and effective healthcare services and benefit utilization.
• Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management.

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.
• Eligibility for a CVS Health bonus, commission, or short-term incentive program.

What This Job Offers

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