Utilization Management Nurse Consultant (Remote)

CVS Health•Work At Home-Alabama, AL

1d•$26 - $56•Remote

About The Position

The Utilization Management Nurse Consultant 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 role gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and judgment to make coverage determinations or recommendations across the continuum of care. It also supports communication and coordination with providers and other parties, identifies referral opportunities and ways to promote quality and effective benefit utilization, and provides expertise to internal and external constituents. This is a remote, work-from-home position with a typical office environment and productivity and quality expectations. Work includes extended periods of sitting, talking on the telephone, listening, and typing, along with close inspection of handwritten and computer-generated documents and a PC monitor. The role requires multitasking, prioritization, adapting to a fast-paced changing environment, computer proficiency, and effective verbal and written communication. Although the listed schedule is standard business hours Monday through Friday, 8:00 a.m.–5:00 p.m. CST, Utilization Management operates 24/7, and work schedules will include weekends, holidays, and evening hours. The position is full-time, with 40 anticipated weekly hours. The company provides computer equipment, including a keyboard, monitor, computer, and headset; the employee provides workspace furniture. A compliant, quiet, secure, private home workspace and a direct, hardwired internet connection meeting the stated speed requirements are required. Work-from-home colleagues must work within the state and city where they have confirmed they currently live.

Requirements

At least 2 years of clinical experience as a Registered Nurse in an adult acute-care or critical-care hospital setting.
Active, current, unrestricted RN licensure in the state of residence.
Ability to work schedules that include weekends, holidays, and evening hours.
Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor.
Ability to sit for extended periods, talk on the telephone, listen, and type on a computer.
Ability to multitask, prioritize, and adapt effectively to a fast-paced changing environment.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Effective verbal and written communication skills.
Ability to obtain and maintain a direct, hardwired internet connection to a modem or router within 7 feet of the computer, with at least 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted.
A quiet, secure, private designated home work location that is free from distractions, organized, compliant with CVS Health and HIPAA guidelines, and permits uninterrupted work.
Ability to work from home within the state and city where the colleague has confirmed they currently live.
Ability to set up and use multiple monitors and navigate multiple applications simultaneously.
Ability to use digital communication tools and Microsoft Office 365 or similar applications.
Ability to access secure systems, follow computer and password security practices, recognize suspicious emails or links, and troubleshoot common technical issues or contact IT when needed.
Openness to learning new skills as the workplace environment evolves.

Nice To Haves

At least 3 years of clinical experience in adult medical-surgical nursing or a specialty area.
Managed care experience, especially utilization management.
Residence in the Central Time Zone.
Bachelor of Science in Nursing (BSN).

Responsibilities

Gather clinical information and apply appropriate 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 quality and effective healthcare services and benefit utilization.
Consult and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management.
Navigate multiple systems and applications, communicate through digital channels, and use secure systems in accordance with security practices.
Meet productivity and quality expectations while adapting to a fast-paced, changing environment.