Utilization Management Nurse Consultant

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

📋 Description

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

• Collect clinical data and utilize clinical criteria, guidelines, policies, procedures, and professional judgment to make coverage decisions or recommendations.

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

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

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

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

• Operate in a standard office setting with expectations for productivity and quality.

• Execute sedentary tasks that involve prolonged sitting, phone conversations, listening, and typing on a computer.

⛳️ Requirements

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

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

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

• Proficient in setting up and utilizing multiple monitors and navigating various applications simultaneously.

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

• Familiarity 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 systems, maintain strong passwords, and identify suspicious emails or links.

• Competence in independently troubleshooting common technical issues.

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

• Minimum internet speed of 50 Mbps for downloads and 5 Mbps for uploads.

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

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

• An Associate's Degree is required.

• Ability to meet and adhere to required work-from-home internet and workspace specifications.

• Capability to perform close inspections of handwritten and computer-generated documents as well as the PC monitor.

• Proficiency in computer use, keyboarding, multitasking, prioritization, and effectively adapting to a fast-paced and changing environment.

• Strong verbal and written communication skills.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.

• Company-provided equipment, including keyboard, monitor, computer, headset, and more.