Utilization Management, Nurse Consultant (Remote)

CVS Health•York, PA

3d•$32 - $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 make coverage determinations or recommendations along the continuum of care. The nurse 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 promote 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. Utilization Management is a 24/7 operation. Schedules include weekends, holidays, and evening hours, typically 12 weekend days per year, one major and one minor holiday per year, and one 7:00 p.m. shift per month. The position has a typical office working environment with productivity and quality expectations. It requires close inspection of handwritten and computer-generated documents and a PC monitor, extended periods of sitting, telephone communication, computer typing, multitasking, prioritization, and adapting to a fast-paced, changing environment. Computer proficiency is needed to navigate multiple systems and keyboard efficiently. This is a remote work-from-home position. Employees must work from the state and city where they have confirmed they currently live and maintain a quiet, secure, private, and distraction-free designated workspace that complies with CVS Health and HIPAA guidelines. A direct, hardwired internet connection to a modem or router within seven feet of the computer is required, with minimum speeds of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides work equipment, while employees provide their own desk or standing desk. The employee must meet the internet and work-from-home requirements.

Requirements

At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
Active, current, unrestricted RN licensure in the state of residence.
Ability to work a schedule that includes weekends, holidays, and evening hours, typically 12 weekend days per year, one major and one minor holiday per year, and one 7:00 p.m. shift per month.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to communicate using email, calendar invitations, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, and PowerPoint) or similar tools such as Google Workspace.
Ability to access secure systems such as VPNs and EHR portals, secure a computer when unattended, manage strong passwords, and recognize suspicious emails or links.
Ability to troubleshoot common technical problems independently and contact IT for unresolved issues.
Openness to learning new skills as the workplace environment evolves.
Ability to obtain and maintain a direct, hardwired internet connection within 7 feet of the computer, with minimum speeds of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
A quiet, secure, private, designated home workspace that is free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and suitable for uninterrupted work.
Work from within the state and city where the employee has confirmed they currently live.
Provide personal workspace furniture, such as a desk or standing desk.
Associate degree required.
Effective verbal and written communication skills.
Ability to sit for extended periods, talk on the telephone, type, inspect handwritten and computer-generated documents, and adapt to a fast-paced changing environment.

Nice To Haves

At least 2 years of clinical experience in a medical-surgical or specialty area.
Managed care experience, especially Utilization Management.
Residence in an Eastern time zone.
BSN preferred.

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 along 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 coordinating and administering utilization and benefit management.