Utilization Management Nurse Consultant

CVS Health • Work At Home-Kansas, KS

1d • $26 - $56 • Remote

About The Position

CVS Health is hiring a remote Registered Nurse for its Utilization Management team. In this non-bedside role, the nurse uses clinical expertise, established guidelines, policies, and clinical judgment to support coverage determinations and help members receive appropriate care. The position assesses, coordinates, monitors, and evaluates healthcare services and benefits across the continuum of care, while collaborating with providers, members, care teams, and other stakeholders. The nurse also connects members with relevant programs and resources and identifies opportunities to improve care quality, health outcomes, and benefit utilization.

This is a computer-based work-from-home role within a 24/7 operation, with productivity and quality expectations. Schedules may include evenings, weekends, and holidays. The role requires a quiet, secure, private, and uninterrupted home workspace that meets company and HIPAA guidelines, as well as a wired internet connection meeting the stated speed requirements. Employees must work within the state and city where they have confirmed residence. CVS Health provides computer equipment and related accessories; employees provide their own workspace furniture. The position is full-time, with 40 anticipated weekly hours.

Requirements

• Active, unrestricted RN license in the state of residence.
• At least 2 years of adult acute care and/or critical care nursing experience.
• Associate Degree in Nursing.
• Strong clinical assessment, critical thinking, and communication skills.
• Ability to multitask and thrive in a fast-paced environment.
• Proficiency navigating multiple computer systems and applications.
• Ability to obtain and use a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted.
• Ability to maintain a quiet, secure, private, organized, distraction-free home workspace that complies with CVS Health and HIPAA guidelines and allows uninterrupted work.
• Ability to work within the state and city where the employee has confirmed current residence.
• Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
• Ability to communicate using digital tools such as email, calendar invitations, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to access secure systems such as VPNs and EHR portals, secure devices and passwords, and recognize suspicious emails or links.
• Ability to troubleshoot common technical issues independently and contact IT for unresolved issues.
• Openness to learning new skills as the workplace environment evolves.

Nice To Haves

• At least 2 years of Med-Surg or specialty nursing experience.
• Managed Care or Utilization Management experience.
• Residence in a Central Time Zone.
• Bachelor of Science in Nursing (BSN).

Responsibilities

• Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations.
• Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care.
• Collaborate with providers and care teams to facilitate appropriate treatment and care planning.
• Identify opportunities to improve quality of care, health outcomes, and benefit utilization.
• Connect members with additional programs and resources that support their healthcare needs.
• Serve as a clinical resource for internal and external stakeholders.

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
• Career Level: Mid Level
• Education Level: Associate degree