Utilization Management Nurse Consultant

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

📋 Description

• Evaluate clinical information and utilize evidence-based criteria to provide coverage recommendations.

• Collaborate with healthcare providers and interdisciplinary teams to enhance member care.

• Identify areas for improvement in healthcare quality, outcomes, and benefit utilization.

• Facilitate referrals to additional programs and services that cater to member needs.

• Act as a clinical resource for both internal and external stakeholders.

• Use clinical expertise to evaluate medical necessity, coordinate care, and ensure that members access appropriate healthcare benefits.

• Operate within a 24/7 environment, with schedules that may include evenings, weekends, and holidays.

⛳️ Requirements

• Valid, unrestricted RN license in your state of residence.

• Minimum of 2 years of RN experience in adult acute care, critical care, medical-surgical, or specialty environments.

• Excellent clinical judgment, communication, and multitasking abilities.

• Capacity to operate efficiently across multiple computer systems in a productivity-focused setting.

• Associate’s Degree in Nursing is required.

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

• Internet speed must be at least 25 Mbps for download and 3 Mbps for upload.

• WiFi and satellite internet connections are not acceptable.

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

• Must be able to work in the state and city where currently residing.

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

• Capability to communicate through email, calendar invites, Teams messaging, and virtual meetings.

• Familiarity with Microsoft Office 365 applications or comparable Google Workspace applications.

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

• Competence in locking computer screens when unattended, managing strong passwords, and identifying suspicious emails or links.

• Ability to independently resolve common technical issues and contact IT for unresolved problems.

• Willingness to learn new skills as the workplace evolves.

• BSN is preferred.

• Experience in Utilization Management or Managed Care is preferred.

• Preference for candidates residing in the Eastern Time Zone.

🏝️ 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 including keyboard, monitor, computer, and headset.

• Remote work arrangement.