Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Alabama, +33 more locations.

📋 Description

• Perform reviews for utilization management and prior authorization.

• Ensure that members obtain medically appropriate and cost-effective care in alignment with clinical guidelines and benefit plans.

• Evaluate cases and make decisions regarding coverage.

• Utilize clinical expertise and critical thinking skills in a non-bedside capacity.

• Collaborate effectively with healthcare providers and interdisciplinary teams.

• Facilitate care coordination and promote high-quality healthcare outcomes.

• Operate remotely from a designated home office while adhering to CVS Health and HIPAA regulations.

⛳️ Requirements

• Valid and unrestricted Registered Nurse (RN) license in the state of residence.

• Associate Degree in Nursing (ADN) or a higher qualification.

• At least 3 years of clinical RN experience.

• A minimum of 1 year of experience in Medical-Surgical (Med/Surg) nursing.

• Strong skills in clinical assessment, analysis, and decision-making.

• Proficient in Microsoft Office applications, including Outlook, Teams, and Excel.

• Available to work Monday through Friday from 9:00 AM to 6:00 PM EST.

• Willingness to support a 24/7 Utilization Management operation, which may include occasional holidays, evening shifts, and changes to the schedule.

• Direct or hardwired internet connection with a minimum of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not acceptable.

• A quiet, secure, private, and HIPAA-compliant designated home workspace.

• Ability to utilize multiple monitors and navigate various applications.

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

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

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

• Ability to independently troubleshoot common technical issues.

• Preferred: Understanding of Medicare guidelines, medical necessity criteria, and evidence-based review processes.

• Preferred: Prior experience in Utilization Management, Prior Authorization, or Concurrent Review.

• Preferred: Clinical experience on the managed care, health plan, or payer side.

• Preferred: Familiarity with MedCompass or similar utilization management systems.

• Preferred: Experience in ambulatory surgery, procedural, or perioperative nursing.

• Preferred: Bachelor of Science in Nursing (BSN).

• Preferred: Experience working collaboratively with physicians, providers, and interdisciplinary healthcare teams.

🏝️ Benefits

• Eligible for 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.

• Retirement savings options available.

• Access to wellness programs.

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

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