Utilization Management Nurse Consultant (EST)

CVS Health • New York, MA

1d • $26 - $56 • 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 make 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 opportunities to other products, services, or programs, and identifies opportunities to improve the quality and effectiveness of healthcare services and benefit utilization. The role also provides expertise to internal and external constituents in coordinating and administering utilization and benefit management functions.

This is a work-from-home role for candidates residing in an Eastern Time Zone state and city where they currently live. The work involves a typical office environment with productivity and quality expectations, extended periods of sitting, telephone communication, listening, and computer use. The position requires close inspection of documents and a computer monitor, multitasking, adapting to a changing environment, and proficiency navigating multiple systems and keyboarding. Candidates must meet the stated home-workspace and internet requirements.

Requirements

• Reside in an Eastern Time Zone state and city where the candidate currently lives.
• Hold an active and unrestricted Registered Nurse (RN) license in the state of residence.
• Have at least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
• Be available to work weekends, holidays, and evening hours as required by business needs.
• Have an Associate Degree in Nursing.
• Have or be able to obtain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with at least 25 Mbps download and 3 Mbps upload speeds; WiFi and satellite internet are not permitted.
• Maintain a quiet, secure, private, tidy, and organized designated home work location compliant with CVS Health and HIPAA guidelines, with no distractions and the ability to work uninterrupted during work hours.
• Be proficient with computer skills, including navigating multiple systems and keyboarding.
• Have effective verbal and written communication skills.
• Be able to multitask, prioritize, and adapt effectively to a fast-paced, changing environment.
• Be comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
• Be able to use collaboration and scheduling applications such as Microsoft Office 365 or similar tools.
• Be able to resolve common technical issues independently and contact IT for issues that cannot be resolved.
• Provide workspace furniture, such as a desk or standing desk, for extended periods of desk work.

Nice To Haves

• At least 2 years of clinical experience in a medical-surgical or specialty area.
• Managed care experience, especially Utilization Management.
• A Bachelor’s Degree in Nursing.

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 make 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, or programs.
• Identify opportunities to promote the quality and effectiveness of healthcare services and benefit utilization.
• Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management functions.
• Navigate multiple systems and applications and communicate through digital channels, including email, calendar invites, Teams messaging, and virtual meetings.
• Follow secure-system practices, including managing passwords, locking unattended computer screens, and recognizing suspicious emails or links.

Benefits

• Eligibility for a CVS Health bonus, commission, or short-term incentive program in addition to base pay.
• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.
• Company-provided computer equipment, including keyboard, monitor, computer, and headset.

What This Job Offers

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