Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in California, +4 more states.

📋 Description

• Evaluate, plan, implement, coordinate, monitor, and assess healthcare services and benefit options 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 enhance care and treatment.

• Recognize members for referral opportunities related to various products, services, and programs.

• Discover opportunities to enhance the quality of healthcare services and the effective use of benefits.

• Provide consultation and expertise to both internal and external stakeholders concerning utilization and benefit management.

• Operate within a 24/7 utilization management environment that includes weekend, holiday, and evening shifts.

• Conduct computer-based document review, telephone communications, typing, multitasking, and maneuvering through multiple systems.

⛳️ Requirements

• A minimum of 2 years of experience as a Registered Nurse in an adult acute care or critical care environment.

• Valid, current, and unrestricted RN licensure in the state of residence.

• Willingness to work on weekends, holidays, and during evening hours, including approximately 12 weekend days per year, 2–3 late shifts, and 1 major and 1 minor holiday per year.

• Proficient in setting up and using multiple monitors and navigating various applications simultaneously.

• Effective communication through email, calendar invitations, Teams messaging, and virtual meetings.

• Familiarity with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or comparable Google Workspace applications.

• Capacity to log into secure systems such as VPN and EHR portals.

• Ability to adhere to computer security protocols, including screen locking, strong password management, and identifying suspicious emails or links.

• Skill in resolving common technical issues independently and reaching out to IT for unresolved problems.

• Willingness to learn new skills as the workplace evolves.

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

• Minimum internet speed requirement of 50 Mbps download and 5 Mbps upload; WiFi and satellite internet are not acceptable.

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

• Must work within the state and city where currently residing.

• Must provide necessary workspace furniture, such as a desk or standing desk.

• Must achieve required internet speeds and adhere to Work From Home requirements if hired.

• An associate degree is required.

• Experience in Managed Care is preferred, particularly in Utilization Management.

• A minimum of 2 years of clinical experience in med surg or a specialized area is preferred.

• Preference will be given to candidates residing in PST time zones.

🏝️ 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 initiatives.

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

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