Utilization Management Nurse Consultant

CVS Health • Work At Home-Kansas, KS

2d • $26 - $56 • 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. 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 looks for ways to promote quality and effective healthcare services and benefit utilization. The position also provides expertise to internal and external constituents supporting utilization and benefit management.

This is a remote position in the Central Time zone. Utilization Management operates 24/7, and schedules include weekends, holidays, and evening hours. Listed schedules are 3–11 or 11–8. The role involves a typical office working environment with productivity and quality expectations. Work is sedentary and involves extended periods of sitting, telephone conversations, listening, and computer typing. The position requires close inspection of handwritten and computer-generated documents and a PC monitor, effective multitasking and prioritization in a fast-paced, changing environment, proficiency navigating multiple computer systems, keyboarding, and strong verbal and written communication skills.

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.
• 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.
• Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor.

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 a Central 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 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 integrate with 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.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being, based on eligibility
• Eligibility for a CVS Health bonus, commission, or short-term incentive program

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree