Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Kentucky, +4 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 judgment to make coverage determinations or recommendations.

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

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

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

• Offer consultation and expertise to both internal and external parties regarding utilization and benefit management.

• Operate in a 24/7 environment, including weekends, holidays, and evening shifts.

• Carry out tasks in a standard office work environment while meeting productivity and quality standards.

• Review handwritten and computer-generated documents as well as PC monitors.

• Remain seated for prolonged periods, engage in telephone conversations, and type on a computer.

• Manage multiple tasks, prioritize effectively, and adapt to a fast-paced, changing environment.

⛳️ Requirements

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

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

• An Associate's Degree is required.

• A Bachelor of Science in Nursing (BSN) is preferred.

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

• Preference given to candidates residing in EST zones.

• Strong computer skills, including the ability to navigate multiple systems and proficient keyboarding.

• Capability to use multiple monitors and applications concurrently.

• Proficient in communication via email, calendar invites, Teams messaging, and virtual meetings.

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

• Ability to access secure systems, including VPN and EHR portals.

• Understanding of and ability to adhere to computer and information security practices.

• Capability to independently troubleshoot common technical issues.

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

• Minimum internet speed requirement of 50 Mbps download and 5 Mbps upload.

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

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

• Required to provide personal workspace furniture.

• Must be available to work on weekends, holidays, and during evening hours.

🏝️ 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.).