Utilization Management Nurse Consultant - Weekends S/S/M/T (4-10 hour shifts)

CVS Health • Work At Home-Georgia, GA

2d • $26 - $69

About The Position

This Medicare Predetermination Utilization Management Nurse Consultant role 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 judgment to make coverage determinations or recommendations along the continuum of care. The role also communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products and programs, promotes quality and effective benefit utilization, and provides expertise to internal and external constituents involved in utilization and benefit management.

Utilization Management is a 24/7 operation. After approximately four to five months of training, the schedule is Saturday through Tuesday in 10-hour shifts. Training is Monday through Friday, 7:30 a.m. to 6 p.m. EST. Holiday rotation and evening hours are part of the work schedule.

This is a full-time position with 40 anticipated weekly hours. The typical pay range is $26.01–$68.55 per hour. The role is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. Eligible colleagues receive a benefits package that includes medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.

Requirements

• At least 3 years of experience as a Registered Nurse.
• Active, current, unrestricted RN licensure in the state of residence.
• At least 1 year of Med/Surg experience.
• At least 1 year of experience with Microsoft Office applications, including Outlook, Teams, and Excel.
• Willingness and ability to work Saturday, Sunday, Monday, and Tuesday in 10-hour shifts after approximately 4–5 months of training Monday through Friday, 7:30 a.m.–6 p.m. EST, with occasional holiday rotation.
• Associate degree required.
• Medicare experience is required.

Nice To Haves

• BSN preferred.
• Prior authorization or Utilization Management experience.
• Managed care experience.
• Experience using MedCompass.
• Ambulatory surgery experience.

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 effectiveness of 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 for physical, emotional, and financial well-being, based on eligibility
• Bonus, commission, or short-term incentive program eligibility

What This Job Offers

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