Utilization Management Nurse Consultant

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

📋 Description

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

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

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

• Identify members who are suitable for referrals to additional products, services, and programs.

• Discover opportunities to enhance the quality of healthcare services and effective utilization of benefits.

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

• Maintain a standard work schedule from Monday to Friday, 8:00 AM to 5:00 PM EST, with potential for weekend, holiday, and evening hours.

⛳️ Requirements

• Minimum of 2 years of experience as a Registered Nurse in an adult acute care or critical care environment.

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

• An Associate's Degree is required.

• At least 2 years of clinical experience in medical-surgical or a specialty area.

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

• Preference given to candidates residing in EST time zones.

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

• Capable of communicating through email, calendar invites, Teams messaging, and virtual meetings.

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

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

• Competence in managing strong passwords and identifying suspicious emails or links.

• Ability to independently troubleshoot common technical issues.

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

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

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

• Capability to work within the state and city of current residence.

• Provision of workspace furniture, such as a desk or standing desk.

• Willingness to work weekends, holidays, and evening hours in a 24/7 operational setting.

• Strong verbal and written communication skills.

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

🏝️ 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 to support physical, emotional, and financial well-being.

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