Utilization Management Nurse Consultant

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

📋 Description

• Evaluate clinical information and utilize evidence-based criteria to make decisions regarding coverage and authorizations.

• Partner with physicians, providers, and interdisciplinary teams to foster quality patient outcomes.

• Recognize opportunities for care coordination, case management, and additional healthcare initiatives.

• Encourage effective healthcare utilization and a member-centered approach to care.

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

• Operate within a 24/7 Utilization Management framework.

• Record activities using various systems and documentation platforms.

• Advocate for patients, utilize critical thinking, support healthcare decision-making, and enhance member experiences.

⛳️ Requirements

• Current and unrestricted RN license in your state of residence.

• Minimum of 2 years of Registered Nurse experience in an adult acute care or critical care environment.

• Associate Degree in Nursing (ADN) is required.

• Preference for candidates with 2+ years of Med-Surg or specialty clinical experience.

• Experience in Utilization Management or Managed Care is preferred.

• BSN is preferred.

• Candidates situated in the Eastern Time Zone are highly preferred.

• Willingness to work evenings, weekends, and holidays as the schedule may vary in a 24/7 operation.

• Strong skills in multitasking and communication.

• Proficiency in computer-based work, requiring navigation across multiple systems and documentation platforms.

• A direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload.

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

• Must work within the state and city where you currently reside.

• Capacity to use multiple monitors and navigate various applications.

• Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings.

• Familiarity with Microsoft Office 365 applications or comparable Google Workspace applications.

• Competence in logging into secure systems such as VPN and EHR portals, managing strong passwords, and identifying suspicious emails or links.

• Ability to independently resolve common technical issues and contact IT support when necessary.

• Willingness to learn new skills as the workplace evolves.

🏝️ 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 including keyboard, monitor, computer, and headset.