Utilization Management Nurse Consultant

CVS Health•Work At Home-Ohio, OH

5d•$29 - $62•Remote

About The Position

CVS Health is hiring a remote Registered Nurse for its Utilization Management team. The nurse uses clinical expertise 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 involves communicating with providers and other parties, identifying referrals and opportunities to improve quality and benefit utilization, and advising internal and external partners on utilization and benefit management. This position operates in a typical office environment with productivity and quality expectations. Work is sedentary and involves extended periods of sitting, telephone conversations, listening, typing, close inspection of written and electronic documents, and using a PC monitor. The role requires multitasking, prioritization, adaptability in a fast-paced environment, proficiency navigating multiple computer systems, and effective written and verbal communication. The position is remote, with a preference for candidates in Central or Eastern time zones. The team operates 24/7, so flexibility for evening, weekend, and holiday work is required. Work-from-home colleagues must work from the state and city where they currently live, maintain a private, secure, quiet and HIPAA-compliant workspace, and have a direct wired internet connection meeting the specified speed requirements. The company provides equipment such as a computer, monitor, keyboard, and headset; employees provide their own desk or standing desk.

Requirements

Active, unrestricted RN license in the state of residence.
At least 2 years of RN experience in adult acute care or critical care settings.
Strong clinical assessment, communication, and multitasking skills.
Comfort working in a fast-paced, technology-driven environment.
Associate Degree in Nursing.
Meet the work-from-home requirements, including a direct wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload, and a quiet, secure, private, HIPAA-compliant workspace.
Ability to use multiple monitors and applications, communicate through digital channels, access secure systems, follow security practices, and troubleshoot common technical issues.
Ability to work with productivity and quality expectations and to sit for extended periods while talking on the telephone and typing.

Nice To Haves

At least 2 years of Med-Surg or specialty clinical experience.
Managed Care and/or Utilization Management experience.
Bachelor of Science in Nursing (BSN).
Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.

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, or programs.
Identify opportunities to promote the quality and effectiveness of healthcare services and benefit utilization.
Consult with and advise internal and external constituents on the coordination and administration of utilization and benefit management.