Utilization Management Nurse Consultant

CVS Health•Work At Home-Pennsylvania, PA

7d•$29 - $62•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Make a difference in healthcare from a clinical review and care coordination perspective. We are seeking an experienced Registered Nurse (RN) to join our Utilization Management team. In this role, you will leverage your clinical expertise to review cases, evaluate medical necessity, coordinate care, and support members in accessing appropriate healthcare services and benefits.

Requirements

Active, unrestricted RN license in your state of residence
Minimum 2 years of RN experience in an adult acute care or critical care setting
Associate Degree in Nursing required
Strong communication, organizational, and multitasking skills
Ability to work schedules that may include evenings, weekends, and holidays as part of a 24/7 operation
You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Nice To Haves

2+ years of Med Surg or other specialty clinical experience
Utilization Management and/or Managed Care experience
BSN preferred
Eastern Time Zone residency preferred

Responsibilities

Review clinical information and apply evidence-based guidelines to make coverage recommendations and determinations
Collaborate with providers and healthcare teams to facilitate appropriate care and treatment
Identify opportunities for care management, quality improvement, and member support programs
Provide clinical expertise to internal and external partners on utilization and benefit management activities
Navigate multiple systems while managing a fast-paced, highly collaborative workload
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
Openness to learning new skills in the future as the workplace environment evolves