Utilization Management Nurse Consultant

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

📋 Description

• Evaluate clinical cases and make coverage decisions based on evidence-based guidelines.

• Collaborate with healthcare providers and care teams to ensure suitable treatment coordination.

• Utilize clinical judgment in making decisions related to utilization and benefit management.

• Recognize opportunities to enhance care quality and improve member outcomes.

• Act as a clinical resource for both internal and external stakeholders.

• Operate in a remote, non-bedside utilization management capacity, focusing on Medicare complex spine cases.

⛳️ Requirements

• Active and unrestricted RN license in the state of residence.

• Minimum of 3 years of RN experience, including at least 1 year in Med/Surg.

• Strong skills in clinical assessment and decision-making.

• Proficient in Microsoft Office (Outlook, Teams, Excel).

• Availability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone; schedules may include holidays and evening hours.

• Associate Degree in Nursing required.

• Must possess or be able to establish a direct/hardwired internet connection to a modem/router within 7 feet of the computer.

• Minimum internet speed of 25 Mbps download and 3 Mbps upload is required.

• WiFi and satellite internet connections are not allowed.

• Must have a quiet, secure, and private home workspace that complies with CVS Health and HIPAA guidelines.

• Must work from the state and city of current residence.

• Required to provide personal workspace furniture, such as a desk or standing desk.

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

• Capable of communicating through email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications or equivalent Google Workspace applications.

• Ability to log in to secure systems, including VPN and EHR portals.

• Familiarity with computer security practices, including locking screens, managing strong passwords, and identifying suspicious emails or links.

• Ability to troubleshoot common technical issues independently and reach out to IT when necessary.

• Willingness to learn new skills as the workplace evolves.

• Experience in Utilization Management or Prior Authorization is preferred.

• A background in managed care is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• BSN is preferred.

🏝️ Benefits

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Options for retirement savings.

• Wellness programs.

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

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