Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Connecticut, +10 more states.

📋 Description

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

• Collect clinical information and utilize clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations throughout the continuum of care.

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

• Identify members for referral opportunities related to additional products, services, and programs.

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

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

• Operate in a standard office environment with expectations for productivity and quality.

• Participate in a 24/7 operation with work schedules that may include weekends, holidays, and evening shifts.

⛳️ Requirements

• A minimum of 3 years of clinical experience as a Registered Nurse in a hospital environment, specifically in adult acute care or critical care.

• Current and unrestricted RN licensure in the state of residence.

• At least 3 years of clinical experience in adult medical-surgical or a specialty area.

• Preferred experience in Managed Care, particularly in Utilization Management.

• Candidates residing in the Eastern Standard Time (EST) zone are preferred.

• An Associate or Bachelor of Science in Nursing (BSN preferred).

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

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

• WiFi and satellite internet connections are not acceptable.

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

• Availability to work weekends, holidays, and evening hours as part of a 24/7 operation is required.

• Capacity to perform close inspections of handwritten and computer-generated documents as well as a PC monitor.

• Ability to sit for extended periods, engage in telephone conversations, and type on a computer.

• Skills to multitask, prioritize, and adapt in a fast-paced, changing environment.

• Proficiency in computer use, including navigating multiple systems and keyboarding.

• Strong verbal and written communication skills are necessary.

• Competence in setting up and using multiple monitors while navigating several applications simultaneously.

• Familiarity with email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications or similar Google Workspace applications is preferred.

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

• Capability to manage strong passwords and identify suspicious emails or links.

• Ability to independently resolve common technical issues.

• Willingness to learn new skills as the workplace evolves.

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

🏝️ 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.

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