Utilization Management Nurse Consultant

CVS Health•Work At Home-Ohio, OH

3d•$26 - $75•Remote

About The Position

The Utilization Management Nurse Consultant is a remote Registered Nurse role on CVS Health’s Utilization Management team. The nurse uses clinical expertise in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options that help members access appropriate healthcare services and benefits. The role gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and 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 who may benefit from referrals to other products or programs, and looks for opportunities to improve healthcare-service quality and benefit utilization. The role also provides expertise to internal and external constituents supporting utilization and benefit management. This is a remote position, with a preference for candidates in Central or Eastern time zones. The operation runs 24/7 and requires flexibility for evenings, weekends, and holidays. Work is performed in a typical office or designated home workspace and involves extended periods of sitting, telephone conversations, listening, and computer use. Colleagues must meet the stated home-internet, security, privacy, and workspace requirements. CVS Health provides computer equipment and related peripherals; colleagues provide their own workspace furniture.

Requirements

Active, unrestricted RN license in the state of residence.
At least 2 years of RN experience in adult acute care or critical care settings.
Associate Degree in Nursing.
Effective verbal and written communication skills.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Ability to meet work-from-home requirements, including a direct wired internet connection with at least 25 Mbps download and 3 Mbps upload, a private and secure designated workspace, and compliance with company and HIPAA guidelines.
Ability to work within the state and city where the colleague has confirmed they currently live.
Ability to work the schedule required by a 24/7 operation, including flexibility for evenings, weekends, and holidays.

Nice To Haves

At least 2 years of Med-Surg or specialty clinical experience.
Managed Care and/or Utilization Management experience.
Strong clinical assessment, communication, and multitasking skills.
Comfort working in a fast-paced, technology-driven environment.
Bachelor of Science in Nursing (BSN).
Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to troubleshoot common technical issues independently 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 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 the quality and effectiveness of healthcare services and benefit utilization.
Consult with and provide expertise to internal and external constituents in the coordination and administration of utilization and benefit management.
Navigate multiple computer systems and applications, use digital communication and collaboration tools, and follow secure-system practices.
Adapt to a fast-paced, changing environment while multitasking, prioritizing work, and meeting productivity and quality expectations.