Utilization Management Nurse Consultant

CVS Health•Work At Home-Pennsylvania, PA

1d•$29 - $62

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 nurse 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 role communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products, services, or programs, and promotes quality and effective healthcare services and benefit utilization. The nurse also consults with and 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. The position is performed in a typical office environment with productivity and quality expectations. Work is sedentary, involving extended periods of sitting, telephone conversations, listening, and computer work. It requires close inspection of handwritten and computer-generated documents and a PC monitor, the ability to multitask and prioritize in a fast-paced, changing environment, computer proficiency across multiple systems, keyboarding, and effective verbal and written communication. The position is full-time, with 40 anticipated weekly hours. The pay range is $29.10–$62.32 per hour. The role is eligible for a CVS Health bonus, commission, or short-term incentive program, in addition to base pay. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.

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.
Associate degree required.
Schedules include weekends, holidays, and evening hours.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Effective verbal and written communication skills.
Ability to multitask, prioritize, and adapt effectively 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.
BSN.
Residence in an Eastern Time zone.

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 render 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 quality and effective healthcare services and benefit utilization.
Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management.