Utilization Management Nurse Consultant
About The Position
CVS Health is seeking a Registered Nurse for a remote, computer-based Utilization Management role. The nurse uses clinical expertise in a non-bedside setting to help ensure members receive appropriate care through evidence-based clinical review, care coordination, and healthcare advocacy. The position involves reviewing clinical information and applying established guidelines, policies, and clinical judgment to support coverage determinations; assessing and coordinating services and benefits across the continuum of care; and collaborating with providers and care teams on treatment and care planning. The nurse also identifies opportunities to improve care quality, member outcomes, and healthcare utilization, connects members with relevant programs and resources, and serves as a clinical resource for stakeholders. The position is remote, with the Eastern Time Zone preferred. Utilization Management operates 24/7, and schedules may include evenings, weekends, and holidays. The role has productivity and quality expectations and frequent collaboration with providers, members, and interdisciplinary healthcare teams. Work-from-home requirements include a direct wired internet connection meeting specified speed minimums, a quiet and secure private workspace compliant with CVS Health and HIPAA guidelines, and working from the state and city where the colleague resides. CVS Health provides work equipment such as a computer, monitor, keyboard, and headset; the colleague supplies workspace furniture. The position requires comfort using multiple monitors and applications, digital communication tools, productivity software, secure systems, and basic technical troubleshooting.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 2 years of adult acute care and/or critical care nursing experience.
- Associate Degree in Nursing.
- Strong clinical assessment, critical thinking, and decision-making skills.
- Excellent verbal and written communication skills.
- Ability to multitask and work effectively in a fast-paced environment.
- Proficiency navigating multiple computer systems and applications.
- Ability to meet work-from-home requirements, including a direct wired internet connection with at least 25 Mbps download and 3 Mbps upload, and a quiet, secure, private designated workspace.
- Ability to work within the state and city where the employee currently resides.
- Comfort using multiple monitors and applications, digital communication tools, Microsoft Office 365 or similar tools, and secure systems such as VPNs and EHR portals.
- Ability to handle common technical issues independently and contact IT for unresolved issues.
- Openness to learning new skills as the workplace evolves.
Nice To Haves
- At least 2 years of Med-Surg or specialty nursing experience.
- Managed Care or Utilization Management experience.
- Residence in the Eastern Time Zone.
- BSN.
Responsibilities
- Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations.
- Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care.
- Collaborate with providers and care teams to facilitate appropriate treatment and care planning.
- Identify opportunities to improve quality of care, member outcomes, and healthcare utilization.
- Connect members with programs and resources that support their healthcare needs.
- Serve as a clinical resource for internal and external stakeholders.
- Navigate multiple computer systems and applications, use secure systems, and communicate through digital channels.
- Meet productivity and quality expectations in a remote work environment.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
