Utilization Management Nurse Consultant

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

📋 Description

• Evaluate, strategize, 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.

• Make coverage determinations and recommendations throughout the continuum of care.

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

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

• Spot opportunities to enhance the quality, effectiveness, and utilization of healthcare services.

• Consult and provide guidance to internal and external stakeholders regarding utilization and benefit management.

• Adhere to a schedule that may include weekends, holidays, and evening hours in a 24/7 utilization management environment.

• Commit to a full-time schedule of 40 hours per week.

⛳️ Requirements

• 3–5 years of Med/Surg experience.

• Over 3 years of experience as a Registered Nurse (RN).

• At least 1 year of inpatient hospital experience.

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

• Proficiency in navigating multiple IT platforms and systems.

• A minimum of 1 year of experience with Microsoft Office applications (Outlook, Teams, Excel).

• An Associate's Degree is required.

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

• Minimum internet speeds of 25 Mbps download and 3 Mbps upload.

• WiFi and satellite internet connections are not acceptable.

• 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.

• Capability to use multiple monitors and navigate various applications simultaneously.

• Competence in utilizing email, calendar invites, Teams messaging, and virtual meetings.

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

• Ability to access secure systems such as VPN and EHR portals.

• Knowledge of computer security practices, including screen locking, strong password management, and recognizing suspicious emails or links.

• Ability to independently troubleshoot common technical issues.

• Willingness to learn new skills as the workplace evolves.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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

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