Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Arizona, +19 more states.

📋 Description

• Evaluate clinical cases and make coverage decisions based on evidence-based guidelines.

• Collaborate with healthcare providers and care teams to ensure appropriate treatment coordination.

• Utilize clinical judgment to facilitate utilization and benefit management decisions.

• Identify areas for enhancing care quality and improving member outcomes.

• Act as a clinical resource for both internal and external stakeholders.

• Leverage clinical expertise to ensure members receive the right care at the right time.

• Operate in a remote, non-bedside utilization management capacity.

• Coordinate care and promote healthcare quality.

⛳️ Requirements

• Current, unrestricted RN license in your state of residence.

• A minimum of 3 years of RN experience, including at least 1 year in Med/Surg.

• Strong skills in clinical assessment and decision-making.

• Proficient in Microsoft Office (Outlook, Teams, Excel).

• Availability to work Monday–Friday, from 9:00 AM to 5:30 PM in your time zone; schedules may include holidays and evenings.

• Associate Degree in Nursing required.

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

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

• A quiet, secure, and private home workspace that complies with CVS Health and HIPAA standards.

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

• Ability to utilize multiple monitors and navigate various applications.

• Experience with Microsoft Office 365 applications or similar tools like Google Workspace.

• Capability to log in to secure systems such as VPN and EHR portals.

• Ability to maintain computer and password security, and recognize suspicious emails or links.

• Proficient in troubleshooting common technical issues independently.

• Must meet required internet speeds and comply with Work From Home policies if hired.

• Experience in Utilization Management or Prior Authorization is preferred.

• A background in managed care is preferred.

• Familiarity with MedCompass is preferred.

• Experience in ambulatory surgery is preferred.

• BSN is preferred.

🏝️ Benefits

• 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.

• Wellness programs.

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

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

• Opportunity for remote work from home.