Utilization Management Nurse Consultant

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

📋 Description

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

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

• Communicate effectively with providers and other stakeholders to facilitate care and treatment.

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

• Pinpoint opportunities to enhance the quality of healthcare services and optimize benefit utilization.

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

• Conduct Medicare clinical predetermination and utilization management activities.

⛳️ Requirements

• Minimum of 3 years of experience as a Registered Nurse.

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

• At least 1 year of Med/Surg experience.

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

• Willingness and ability to work Monday through Friday, from 9:00 AM to 5:30 PM Eastern or Central time, with occasional holiday rotation; schedules may include holidays and evening hours.

• Experience in Prior Authorization or Utilization Management is preferred.

• Prior managed care experience is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• An Associate’s degree is required.

• A BSN is preferred.

• A direct/hardwired internet connection to modem/router within 7 feet of the computer is necessary.

• Minimum internet speed of 25 Mbps download and 3 Mbps upload is required.

• WiFi and satellite internet connections are not acceptable.

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

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

• Ability to use multiple monitors and navigate various applications is essential.

• Experience with Microsoft Office 365 applications or comparable Google Workspace tools is necessary.

• Ability to log in to secure systems such as VPN and EHR portals is required.

• Must maintain computer and data security.

• Ability to independently troubleshoot common technical issues is essential.

🏝️ Benefits

• 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.).

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