Utilization Management Nurse Consultant

CVS Health • Work At Home-Texas, NV

2d • $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 along the continuum of care. The nurse 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 consults with and provides expertise to internal and external constituents coordinating and administering utilization and benefit management.

This is a work-from-home role. Employees must work from a quiet, secure, private, and uninterrupted home workspace in the state and city where they currently live. The role requires a direct wired internet connection meeting specified minimum speeds; Wi-Fi and satellite internet are not permitted. The company provides computer equipment, but employees provide their own desk or standing desk. The role involves extended periods at a desk and navigating multiple monitors, applications, secure systems, and digital communication tools.

Requirements

• At least 3 years of experience as a Registered Nurse.
• Active, current, and unrestricted RN licensure in the state of residence.
• At least 1 year of Med/Surg experience.
• At least 1 year of experience with Microsoft Office applications, including Outlook, Teams, and Excel.
• Associate degree required.
• Ability to meet the work-from-home requirements, including a wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload, and a quiet, secure, private workspace.
• Ability to work Monday through Friday; the posting lists schedules of 9:00 a.m.–5:30 p.m. Eastern or Central time, and elsewhere lists 9:00 a.m.–6:00 p.m. Eastern with a one-hour lunch or 9:30 a.m.–6:00 p.m. Eastern with a 30-minute lunch.
• Willingness and ability to participate in occasional holiday rotation; the posting also notes that utilization management is a 24/7 operation and schedules include holidays and evening hours.
• Comfort navigating multiple monitors and applications and communicating through digital channels, including email, calendar invites, Teams messaging, and virtual meetings.
• Ability to use secure systems, follow security practices, troubleshoot common technical issues, and learn new skills as the workplace evolves.

Nice To Haves

• Prior Authorization or Utilization Management experience.
• Managed care experience.
• Experience using MedCompass.
• Ambulatory surgery 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 make coverage determinations or recommendations.
• 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 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
• Career Level: Mid Level
• Education Level: Associate degree