Utilization Management Nurse Consultant
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. This role is Telework anywhere! Preference for Virginia residents or out of state residents that have the Virginia licensure and/or compact licensure. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification. Most of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Sedentary work involves periods of sitting, talking, listening and computer use
Requirements
- Must have active, current and unrestricted RN licensure in state of residence with at least an Associate’s Degree
- 3+ years of clinical experience in nursing
- Must be wiling and able to work Monday - Friday 8 am - 5 pm with occasional weekend/holiday on-call or rotating 10 hour shifts
- Proficient computer skills which include navigating multiple systems
- Ability to work in a fast-paced environment
- 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.
- 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
Nice To Haves
- Previous prior authorization experience
- Compact RN licensure
Responsibilities
- Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification.
- Collects and reviews clinical information from providers.
- Uses specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
