Utilization Management Nurse Consultant

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

📋 Description

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

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

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

• Identify members for referral opportunities related to other products, services, and programs.

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

• Consult and offer expertise to both internal and external stakeholders in the coordination and administration of utilization and benefit management.

• Maintain a Monday-Friday work schedule from 8:00 AM to 5:00 PM CST, including 12 weekend shifts annually, occasional weekend shifts, and 2 holidays per year, subject to change.

⛳️ Requirements

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

• Current and unrestricted RN licensure in the state of residence.

• An Associate's Degree is required.

• At least 2 years of clinical experience in medical-surgical or specialty areas.

• Preferred experience in Managed Care, particularly in Utilization Management.

• Preference will be given to candidates residing in CST time zones.

• Proficiency in setting up and using multiple monitors while navigating various applications simultaneously.

• Capability to communicate through email, calendar invitations, Teams messaging, and virtual meetings.

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

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

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

• 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 permitted.

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

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

• Willingness to work weekends, holidays, and evening hours in a 24/7 operational environment.

• Ability to perform close inspections of handwritten and computer-generated documents as well as PC monitors.

• Capability to sit for extended durations, engage in telephone conversations, and type on a computer.

• Proficient computer skills, including navigating multiple systems and keyboarding.

• Strong verbal and written communication skills.

🏝️ Benefits

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

• 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.).