Utilization Management Nurse Consultant

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

📋 Description

• Oversee, document, and communicate all elements of the utilization and benefit management program.

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

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

• Liaise 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 and effectiveness of healthcare services and benefit utilization.

• Provide consultation and expertise to both internal and external constituents in managing and administering the utilization and benefit management function.

• Review services for medical necessity and appropriate benefit usage.

• Support safe and efficient discharge planning.

• Collaborate with facilities and providers to address complex member needs.

• Examine written clinical records.

• Minimal travel, potentially up to 10%, may be required for clinical audits.

⛳️ Requirements

• Must possess an active, current, and unrestricted RN license in the state of residence.

• 2+ years of recent acute hospital clinical experience as an RN, with "recent" defined as within the last 10 years.

• 1+ years of experience with Microsoft Office applications including PowerPoint, Excel, and Word.

• Must be willing and able to work Monday through Friday from 8:00 AM to 4:30 PM in the time zone of residence.

• Must be prepared to work a weekend and holiday rotation as required by the department.

• Utilization Review experience is preferred.

• A background in Managed Care is preferred.

• Strong telephonic communication skills are preferred.

• An Associate's Degree in Nursing is required.

• A Bachelor’s Degree in Science & Nursing is preferred.

🏝️ 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, based on eligibility.