Utilization Management Nurse Consultant

CVS Health • Work At Home-Illinois, IL

2d • $26 - $69 • Remote

About The Position

Utilizes 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. Gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations along the continuum of care. Communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products, services, or programs, and identifies opportunities to promote quality, effectiveness of Healthcare Services, and benefit utilization. Consults with and lends expertise to internal and external constituents in coordinating and administering utilization and benefit management functions.

The role is performed from a designated home workspace. It involves extended periods of sitting, talking on the telephone, listening, and typing, and requires close inspection of handwritten and computer-generated documents and a PC monitor. The work requires multitasking, prioritization, adaptability in a fast-paced changing environment, computer proficiency, navigation of multiple systems, and effective verbal and written communication.

The employee must meet work-from-home requirements, including a direct wired internet connection with specified minimum speeds, a quiet and secure private workspace compliant with CVS Health and HIPAA guidelines, and working within the state and city where they currently live. The company provides equipment such as a keyboard, monitor, computer, and headset; employees provide their own workspace furniture. The role requires comfort with multiple monitors and applications, digital communications and virtual meetings, Microsoft Office 365 or similar tools, secure system access and cybersecurity practices, and basic technical troubleshooting. The employee must be open to learning new skills as the workplace evolves.

Requirements

• Must reside in the Central, Mountain, or Pacific time zone.
• Must hold an active, current, and unrestricted Registered Nurse (RN) license in the state of residence.
• At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
• Must be available to work weekends, holidays, and evening hours as required by business needs.
• Associates Degree in Nursing or Nursing Diploma.
• Must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
• Must maintain a quiet, secure, private, designated home workspace that is free from distractions, organized, compliant with CVS Health and HIPAA guidelines, and allows uninterrupted work during working hours.
• Must work from within the state and city where the employee has confirmed they currently live.
• Must provide workspace furniture, such as a desk or standing desk, and adhere to all work-from-home requirements.
• Must be comfortable using multiple monitors and navigating multiple applications simultaneously.
• Must be able to use digital communication channels, including email, calendar invitations, Teams messaging, and virtual meetings.
• Must have experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
• Must be able to access secure systems, follow basic computer security practices, and recognize suspicious emails or links.
• Must be able to troubleshoot common technical issues independently and contact IT for unresolved issues.
• Must have effective verbal and written communication skills.
• Must be proficient with computer skills, including navigating multiple systems and keyboarding.
• Must be able to multitask, prioritize, and adapt effectively to a fast-paced, changing environment.

Nice To Haves

• At least 2 years of clinical experience in a medical-surgical or specialty area.
• Managed care experience, especially Utilization Management.

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, and programs.
• Identify opportunities to promote quality and 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 functions.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility
• Eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay

What This Job Offers

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