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 members receive suitable healthcare services and benefits.

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

• Interact with providers and other stakeholders to facilitate care and treatment processes.

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

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

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

• Work remotely from the designated residential city and state.

⛳️ Requirements

• A minimum of 3 years of experience as a Registered Nurse.

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

• At least 1 year of Med/Surg experience.

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

• An Associate degree is required.

• Experience in Prior Authorization or Utilization Management is preferred.

• Managed care experience is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• Availability to work Monday through Friday during specified Eastern or Central time hours, with occasional holiday rotation.

• Willingness and capability to work evening hours and holidays as part of a 24/7 Utilization Management operation.

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

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

• Proficiency in using multiple monitors and navigating various applications.

• Capability to use digital communication channels and virtual meeting tools.

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

• Ability to access secure systems such as VPN and EHR portals while adhering to security protocols.

• Competence in troubleshooting common technical issues independently.

• A willingness to acquire 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.

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

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