Utilization Management Nurse Consultant (Remote, EST/CST)

CVS Health•New York, NY

2d•$29 - $62•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 also 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 ways to promote quality and effective healthcare services and benefit utilization. The position consults with and provides expertise to internal and external constituents involved in utilization and benefit management. Utilization Management is a 24/7 operation. The schedule includes weekends, holidays, and evening hours, approximately 12 weekend days per year, one evening shift per month, and one major and one minor holiday per year. The role is remote, with work-from-home requirements including a quiet, secure, private, and HIPAA-compliant designated workspace, a direct wired internet connection meeting specified speed requirements, and working from the state and city where the colleague resides. CVS Health provides equipment such as a keyboard, monitor, computer, and headset; the colleague provides workspace furniture. The work is sedentary and involves extended periods sitting, talking on the telephone, listening, and typing, as well as close inspection of handwritten and computer-generated documents and a PC monitor. The role requires multitasking, prioritization, adaptability, computer proficiency, and effective verbal and written 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.
Ability to work schedules that include weekends, holidays, and evening hours.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to communicate using digital channels such as email, calendar invites, Teams messaging, and virtual meetings.
Experience using Microsoft Office 365 applications or similar tools, such as Google Workspace.
Ability to access secure systems, use computer security practices, manage strong passwords, and recognize suspicious emails or links.
Ability to resolve common technical issues independently and contact IT for unresolved issues.
Openness to learning new skills as the workplace environment evolves.
Ability to obtain and maintain a direct, hardwired internet connection to a modem or router within 7 feet of the computer, with a minimum speed of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
A quiet, secure, private, organized, and HIPAA-compliant home workspace that allows uninterrupted work during working hours.
Must work from the state and city where the employee has confirmed they currently live.
Must provide workspace furniture, such as a desk or standing desk, and adhere to the stated work-from-home requirements.
Associate degree required.
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.

Nice To Haves

At least 2 years of clinical experience in med-surg or a specialty area.
Managed care experience, especially Utilization Management.
Residence in an Eastern time zone.
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 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, or programs.
Identify opportunities to promote quality and effective healthcare services and benefit utilization.
Consult with and provide expertise to internal and external constituents in the coordination and administration of utilization and benefit management.