Utilization Management Nurse Consultant

CVS Health • Washington, NV

2d • $26 - $69 • Remote

About The Position

The Medicare Precertification 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. The nurse communicates with providers and other parties to facilitate care and treatment, identifies members for referral opportunities to other products, services, or programs, and identifies opportunities to promote quality and effective healthcare services and benefit utilization. The role also consults with and provides expertise to internal and external constituents in coordinating and administering utilization and benefit management.

The stated schedule is Monday through Friday, 9:00 a.m. to 5:30 p.m. in the candidate’s time zone. Utilization Management operates 24/7, and schedules may include holidays and evening hours. This is a work-from-home position with requirements for a suitable wired internet connection, a quiet and secure designated workspace, and residence in the state and city confirmed to the employer. The company provides computer equipment and other listed peripherals; colleagues provide their own desk or standing desk. The position requires extended periods at a desk and use of multiple monitors and applications.

Requirements

• At least 3 years of experience as a Registered Nurse.
• Active, current, unrestricted RN licensure in the state of residence.
• At least 1 year of Med/Surg experience.
• At least 1 year of experience with Microsoft Office applications, including Outlook, Teams, and Excel.
• Associate degree required.
• Ability to meet the work-from-home requirements, including a direct wired internet connection with the specified minimum speeds, a quiet and secure workspace, and working from the state and city where the candidate has confirmed residence.
• Ability to set up and use multiple monitors and navigate multiple applications simultaneously.
• Ability to communicate using digital tools such as email, calendar invitations, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to access secure systems, follow basic computer and account security practices, and recognize suspicious emails or links.
• Ability to troubleshoot common technical issues and contact IT for unresolved issues.
• Willingness to learn new skills as the workplace environment evolves.

Nice To Haves

• BSN.
• Prior Authorization or Utilization Management experience.
• Managed care experience.
• Experience using MedCompass.
• Ambulatory surgery experience.
• Medicare experience.

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, 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 coordinating and administering utilization and benefit management.

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources 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