Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in New Hampshire, +11 more states.

📋 Description

• Evaluate, plan, implement, coordinate, oversee, and assess options to ensure that members receive suitable healthcare services and benefits.

• Collect clinical data and utilize clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage decisions or recommendations.

• Engage with providers and other stakeholders to enable effective care and treatment.

• Recognize members for referral opportunities related to additional products, services, or programs.

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

• Offer consultation and expertise to internal and external stakeholders in managing and administering utilization and benefit management.

• Operate within a 24/7 utilization management framework.

⛳️ Requirements

• 3-5 years of experience in Med/Surg.

• A minimum of 3 years as a Registered Nurse (RN).

• At least 1 year of experience in an inpatient hospital setting.

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

• Proficient in working with multiple IT platforms and systems.

• 1+ year of experience using Microsoft Office applications (Outlook, Teams, Excel).

• An Associate's Degree is required.

• Experience with Medicare/Medicaid populations is preferred.

• Familiarity with MCG is preferred.

• Managed care experience is preferred.

• UM Certification is preferred.

• MedCompass experience is preferred.

• Over 1 year of inpatient utilization experience is preferred.

• Must be available to work weekends, holidays, and evening shifts as part of a 24/7 operation.

• A 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.

• A quiet, secure, and private designated home workspace compliant with CVS Health and HIPAA regulations is essential.

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

• Capacity to achieve necessary internet speeds and comply with Work From Home requirements.

• Ability to set up and utilize multiple monitors and navigate various applications.

• Proficient in using digital communication tools, email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications or equivalent Google Workspace applications is required.

• Capability to log in to secure systems such as VPN and EHR portals, manage strong passwords, and identify suspicious emails or links.

• Ability to independently troubleshoot common technical issues.

• Willingness to learn new skills as the workplace evolves.

🏝️ 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 (keyboard, monitor, computer, headset, etc.).