Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Alabama, +45 more states.

📋 Description

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

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

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

• Recognize members for referral opportunities involving additional products, services, and programs.

• Discover opportunities to enhance the quality of healthcare services and benefit usage.

• Collaborate with and offer expertise to both internal and external parties in the coordination and administration of utilization and benefit management.

• Work Monday to Friday, from 9:00 a.m. to 5:30 p.m. in the candidate's time zone, with holidays and evening shifts as part of the 24/7 operation.

• Commit to approximately 40 hours per week.

⛳️ Requirements

• Over 3 years of experience as a Registered Nurse.

• Must possess an active, current, and unrestricted RN license in the state of residence.

• At least 1 year of Med/Surg experience.

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

• An Associate's degree is required.

• Prior Authorization or Utilization Management experience is preferred.

• Managed care experience is preferred.

• Experience with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• Medicare experience is preferred.

• A BSN is preferred.

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

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

• WiFi and satellite internet connections are not permitted.

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

• Candidate must work within the state and city of their current residence.

• Provision of personal workspace furniture is necessary.

• Experience with multiple monitors and navigating applications simultaneously is required.

• Proficiency in using email, calendar invites, Teams messaging, and virtual meetings is essential.

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

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

• Capability to maintain computer security, employ strong passwords, and identify suspicious emails or links is essential.

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

• Willingness to learn new skills as the workplace evolves is expected.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Equipment provided by the company, including keyboard, monitor, computer, and headset.