Utilization Management Nurse Consultant - Work at Home - EST

CVS Health•Work At Home-Pennsylvania, PA

6d•$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. It communicates with providers and other parties to facilitate care and treatment, identifies referral opportunities to integrate members with other products, services, or programs, and identifies opportunities to promote quality and effective healthcare service and benefit utilization. The consultant also advises internal and external constituents on coordinating and administering utilization and benefit management. Utilization Management operates 24/7, and schedules may include weekends, holidays, and evening hours. The typical schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. EST, with 40 anticipated weekly hours. The role is performed from home in a typical office environment, with productivity and quality expectations. Work involves extended periods of sitting, telephone conversations, listening, typing, close inspection of handwritten and computer-generated documents, and working at a PC monitor. The employee must be able to multitask, prioritize, and adapt to a fast-paced, changing environment while navigating multiple computer systems. The position requires a designated quiet, secure, private, and organized home workspace that complies with company and HIPAA guidelines and permits uninterrupted work. 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. Work-from-home employees must work within the state and city where they have confirmed they currently live. The company provides equipment such as a keyboard, monitor, computer, and headset; employees provide their own workspace furniture. The role is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. The stated pay range is $29.10–$62.32 per hour.

Requirements

At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
Active, current, and unrestricted RN licensure in the state of residence.
Associate degree required.
Ability to set up and use multiple monitors and navigate multiple applications simultaneously.
Ability to communicate through email, calendar invitations, Teams messaging, and virtual meetings.
Experience using Microsoft Office 365 applications or similar tools such as Google Workspace.
Ability to access secure systems, follow computer and account security practices, and recognize suspicious emails or links.
Ability to resolve common technical issues 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 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 company and HIPAA guidelines, and work from the state and city of confirmed residence.
Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor.
Ability to sit for extended periods, talk on the telephone, listen, and type on a computer.
Ability to multitask, prioritize, and adapt to a fast-paced, changing environment.
Effective verbal and written communication skills.
Availability for a 24/7 operation, which may include weekends, holidays, and evening hours.

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 EST 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 integrate them 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.