Utilization Management, Nurse Consultant (Remote, EST)

CVS Health • New York, NY

2d • $32 - $69 • 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 clinical judgment to render coverage determinations or recommendations across the continuum of care. It also communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products, services, or programs, promotes quality and effective healthcare services and benefit utilization, and consults with internal and external constituents on utilization and benefit management.

Utilization Management operates 24/7, and schedules include weekends, holidays, and evening hours. This remote role has a typical office environment with productivity and quality expectations. Work is sedentary and involves extended periods of sitting, telephone conversations, listening, typing, and close inspection of handwritten and computer-generated documents and a PC monitor. The colleague must multitask, prioritize, adapt to a fast-paced changing environment, and navigate multiple computer systems.

The position requires a designated quiet, secure, private home workspace compliant with company and HIPAA guidelines, along with a direct wired internet connection of at least 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted. Colleagues must work within the state and city where they have confirmed they live. The company provides equipment such as a keyboard, monitor, computer, and headset; the colleague supplies workspace furniture. The role also requires using digital communication and collaboration tools, secure systems, and basic technical troubleshooting, with openness to learning new skills as the workplace evolves.

Requirements

• At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
• Active, current, and unrestricted RN licensure in the state of residence.
• Willingness to work evenings, weekends, and holidays as part of a 24/7 operation.
• Associate degree required.
• Ability to use multiple monitors and applications simultaneously.
• Experience or ability to use Microsoft Office 365 applications or similar collaboration and productivity tools.
• Ability to access secure systems, follow security practices, and resolve common technical issues or contact IT for support.
• Ability to obtain and maintain a direct wired internet connection with at least 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
• Ability to maintain a quiet, secure, private, organized home workspace that complies with company and HIPAA guidelines.
• Must work from the state and city where currently confirmed to live.
• Must provide workspace furniture, such as a desk or standing desk.

Nice To Haves

• At least 2 years of clinical experience in a medical-surgical or specialty area.
• Managed Care experience, especially Utilization Management.
• Residence in the Eastern Time zone.
• Bachelor of Science in Nursing (BSN).

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 make coverage determinations or recommendations across 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 effective healthcare services and benefit utilization.
• Consult with and provide expertise to internal and external constituents on utilization and benefit management.
• Navigate multiple systems and applications and communicate through digital channels, including email, calendar invites, messaging, and virtual meetings.
• Maintain secure system access and follow home-workspace and internet requirements.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources to support physical, emotional, and financial well-being, based on eligibility
• Eligibility for a CVS Health bonus, commission, or short-term incentive program

What This Job Offers

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