Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Arizona, +8 more states.

📋 Description

• Evaluate, plan, implement, coordinate, monitor, and assess options to ensure suitable 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.

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

• Identify members for potential referral opportunities involving various products, services, and programs.

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

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

• Collaborate effectively within a 24/7 Utilization Management operation.

⛳️ 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.

• A 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, including occasional holiday rotation.

• Utilization Management schedules may require working on holidays and evenings.

• Prior Authorization or Utilization Management experience is preferred.

• Managed care experience is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• An Associate's degree is required.

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

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

• A quiet, secure, private designated home virtual work location that complies with CVS Health and HIPAA guidelines is needed.

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

• Must provide workspace furniture.

• Ability to set up and utilize multiple monitors and navigate several applications is essential.

• Competence in communicating via email, calendar invites, Teams messaging, and virtual meetings is required.

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

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

• Ability to adhere to computer and password security practices and identify suspicious emails or links is important.

• Capability to independently troubleshoot common technical issues is necessary.

• Willingness to learn new skills is essential.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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