Utilization Management Nurse Consultant

CVS Health•Work At Home-Georgia, IN

2d•$26 - $56•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 appropriate 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 integrate with other products, services, or programs, and identifies opportunities to promote the quality and effectiveness of Healthcare Services and benefit utilization. Consults with and lends expertise to internal and external constituents in the coordination and administration of utilization and benefit management. The role is performed in a typical office environment with productivity and quality expectations. Work involves close inspection of handwritten and computer-generated documents and a PC monitor, extended periods of sitting, telephone conversations, listening, and computer typing. The position requires multitasking, prioritization, adaptability in a fast-paced changing environment, computer proficiency, navigation of multiple systems, and effective verbal and written communication. This is a work-from-home position. The employee must have or obtain a direct, hardwired internet connection to a modem or router within seven feet of the computer, with at least 25 Mbps download and 3 Mbps upload speeds; Wi-Fi and satellite internet are not permitted. A quiet, secure, private, organized, and distraction-free designated workspace compliant with CVS Health and HIPAA guidelines is required. 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; the employee supplies workspace furniture. The role requires comfort using multiple monitors and applications, digital communication and collaboration tools, Microsoft Office 365 or similar applications, secure systems such as VPNs and EHR portals, and basic troubleshooting of common technical issues.

Requirements

Active 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.
Availability to work weekends, holidays, and evening hours as required by business needs.
Associate degree in Nursing.
Ability to meet work-from-home internet, workspace, location, and security requirements.
Proficiency with computers, keyboarding, and navigating multiple systems and applications.
Effective verbal and written communication skills.
Ability to multitask, prioritize, and adapt effectively in a fast-paced changing environment.
Ability to use digital communication tools and Microsoft Office 365 or similar applications.
Ability to access secure systems, follow security practices, and troubleshoot common technical issues.

Nice To Haves

Bachelor's degree in Nursing.
At least 2 years of clinical experience in med-surg or a specialty area.
Managed care experience, especially Utilization Management.
Residence in an Eastern Standard Time (EST) zone.

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 integrate with other products, services, or programs.
Identify opportunities to promote the quality and effectiveness of Healthcare Services and benefit utilization.
Consult with and lend expertise to internal and external constituents in coordinating and administering utilization and benefit management.