Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Assess, plan, implement, coordinate, monitor, and evaluate options to ensure suitable healthcare services and benefits for members.

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

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

• Identify members for referral opportunities related to other products, services, or benefit programs.

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

• Provide consultation and expertise to internal and external parties in managing and administering utilization/benefit management.

• Achieve productivity and quality benchmarks set by UMNC.

• Work an alternative weekend schedule with coverage required on both Saturday and Sunday.

• Attend occasional on-site meetings, training sessions, or other events at an office or client location when directed.

⛳️ Requirements

• Registered Nurse.

• Diploma RN is acceptable.

• A minimum of 3 years of experience as a Registered Nurse.

• At least 1 year of clinical experience in an acute or post-acute setting.

• A minimum of 1 year of experience in Utilization Management / Care Management.

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

• May be required to obtain additional Nursing Licenses as business needs arise.

• Strong verbal and written communication skills.

• Proficient in computer skills, including navigating multiple systems and keyboarding.

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

• Capacity to sit for extended periods, communicate on the phone, and type on the computer.

• Availability for coverage on both Saturday and Sunday each week.

• Accessibility via phone, videoconference, and email during work hours.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.