Utilization Management Nurse Consultant

CVS Health•Washington, DC

1d•$29 - $62•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. It 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 quality and effective healthcare services and benefit utilization. The nurse consultant also advises internal and external constituents on coordinating and administering utilization and benefit management functions. Utilization Management is a 24/7 operation; schedules include weekends, holidays, and evening hours. The job involves sedentary work, extended periods of sitting, telephone conversations, listening, and computer work, including typing and inspecting handwritten and computer-generated documents. It requires multitasking, prioritizing, adapting to a fast-paced changing environment, computer proficiency, and effective verbal and written communication. This is a work-from-home position. The employee must work from the state and city where they have confirmed residence and maintain a quiet, secure, private home workspace compliant with company and HIPAA guidelines. A wired internet connection to a modem or router within seven feet of the computer is required, with at least 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides equipment such as a keyboard, monitor, computer, and headset, while the employee supplies workspace furniture. The role is full-time, with 40 anticipated weekly hours.

Requirements

At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
Active, current, unrestricted RN license in the state of residence.
Associate degree.
Ability to work a schedule that includes weekends, holidays, and evening hours.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Effective verbal and written communication skills.
Ability to inspect handwritten and computer-generated documents and a PC monitor.
Ability to sit for extended periods, talk on the telephone, type, multitask, prioritize, and adapt to a fast-paced changing environment.
Ability to obtain and maintain a direct, hardwired internet connection with at least 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
Ability to maintain a quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines and work from the state and city of confirmed residence.
Ability to use secure systems and follow security practices, including managing strong passwords and recognizing suspicious emails or links.

Nice To Haves

At least 2 years of clinical experience in medical-surgical nursing or a specialty area.
Managed care experience, especially utilization management.
Residence in a Pacific Time Zone (PST) area.
Bachelor of Science in Nursing (BSN).
Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, and PowerPoint) or similar tools such as Google Workspace.
Experience troubleshooting common technical issues and openness to learning new skills as the workplace evolves.

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 quality and effective healthcare services and benefit utilization.
Consult with and provide expertise to internal and external constituents regarding coordination and administration of utilization and benefit management.
Navigate multiple systems and applications and communicate through digital channels as needed.
Maintain a secure and private home workspace and follow required internet, security, and work-from-home requirements.