Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in California.

📋 Description

• Evaluate, plan, implement, coordinate, monitor, and assess options to ensure appropriate healthcare services and benefits for members.

• Collect clinical information and utilize clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations.

• Engage with providers and other stakeholders to facilitate care and treatment.

• Identify members for referral opportunities that involve other products, services, and programs.

• Recognize opportunities to enhance the quality of healthcare services and optimize benefit utilization.

• Consult with and provide guidance to both internal and external parties regarding utilization and benefit management.

• Operate within a 24/7 utilization management setting, including weekend, holiday, and evening shifts.

• Execute work in a standard office environment with expectations for productivity and quality.

• Review handwritten and computer-generated documents and examine PC monitor content.

• Remain seated for extended periods, engage in telephone conversations, type, multitask, prioritize tasks, and adapt to a fast-paced environment.

⛳️ Requirements

• A minimum of 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.

• Active, current, and unrestricted RN licensure in the state of residence.

• Availability for weekends, holidays, and evening hours, including approximately 12 weekend days per year, 2–3 late shifts, and 1 major and 1 minor holiday per year.

• Comfort with setting up and using multiple monitors and navigating various applications simultaneously.

• Proficient in communicating via email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or comparable Google Workspace applications.

• Ability to log into secure systems such as VPN and EHR portals, manage secure computer access, maintain strong passwords, and identify suspicious emails or links.

• Capability to resolve common technical issues independently and reach out to IT for unresolved problems.

• Direct/hardwired internet connection to a modem/router within 7 feet of the computer.

• Minimum internet speed of 50 Mbps download and 5 Mbps upload; WiFi and satellite internet connections are not acceptable.

• Quiet, secure, private, designated home workspace that complies with CVS Health and HIPAA guidelines.

• Must reside and work within the state and city of current residence.

• Ability to achieve the required internet speeds and adhere to Work From Home requirements.

• An Associate's Degree is required.

• Strong verbal and written communication skills.

• Proficient in computer use, including navigating multiple systems and keyboarding.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• Company-provided equipment (keyboard, monitor, computer, headset, etc.).

• Remote work from home.