Utilization Management Nurse Consultant (Remote, PST)

CVS Health•Washington, NV

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 make coverage determinations or recommendations along the continuum of care. It communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products, services, or programs, and looks for opportunities to promote quality and effective healthcare service and benefit utilization. The consultant also advises internal and external constituents on coordinating and administering utilization and benefit management. Utilization Management operates 24/7. Work schedules include weekends, holidays, and evening hours, with approximately 12 weekend days, 2–3 late shifts, and one major and one minor holiday per year. The position is full-time, with 40 anticipated weekly hours. It is remote, with work-from-home requirements including a quiet, secure, private designated workspace that complies with CVS Health and HIPAA guidelines; a direct, hardwired internet connection within seven feet of the computer, with at least 50 Mbps download and 5 Mbps upload (Wi-Fi and satellite internet are not permitted); and working from the state and city where the employee lives. The company provides work equipment, while the employee supplies workspace furniture. The work takes place in a typical office environment with productivity and quality expectations. It involves sedentary work, extended periods of sitting, talking and listening, telephone communication, computer typing, and close inspection of handwritten and computer-generated documents and a PC monitor. The role requires multitasking, prioritization, adaptability in a fast-paced environment, computer proficiency, navigation of multiple systems, and effective written and verbal communication.

Requirements

At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
Active, current, unrestricted RN licensure in the state of residence.
Associate degree required.
Ability to use multiple monitors and navigate multiple applications simultaneously.
Ability to communicate using email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar applications such as Google Workspace.
Ability to access secure systems such as VPNs and EHR portals, secure devices and passwords, and recognize suspicious emails or links.
Ability to resolve common technical issues independently and contact IT for issues that cannot be resolved.
Ability and willingness to learn new skills as the workplace environment evolves.
Ability to obtain and maintain a direct, hardwired internet connection within seven feet of the computer with minimum speeds of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
A quiet, secure, private, tidy, and organized designated home workspace compliant with CVS Health and HIPAA guidelines and suitable for uninterrupted work.
Must work from the state and city where currently living.
Must provide workspace furniture, such as a desk or standing desk, and meet the work-from-home requirements.
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 to a fast-paced, changing environment.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Effective verbal and written communication skills.
Work schedule includes weekends, holidays, and evening hours, approximately 12 weekend days per year, 2–3 late shifts, and one major and one minor holiday per year.

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 a Pacific Time Zone location.
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 judgment to make 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 effective healthcare services and benefit utilization.
Consult with and provide expertise to internal and external constituents on coordinating and administering utilization and benefit management.