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 suitable healthcare services and benefits for members.

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

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

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

• Recognize opportunities to enhance the quality of healthcare services and promote effective benefit utilization.

• Consult with and provide guidance to both internal and external stakeholders on utilization and benefit management.

• Navigate various systems and applications while achieving productivity and quality standards.

• Operate in a standard office setting that involves sedentary work, prolonged sitting, telephone communication, and computer usage.

⛳️ Requirements

• An Associate's Degree is required.

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

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

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

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

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

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

• Ability to log into secure systems such as VPN and EHR portals, secure a computer, manage strong passwords, and identify suspicious emails or links.

• Competence in troubleshooting common technical issues independently and contacting IT when necessary.

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

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

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

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

• Must supply personal workspace furniture.

• Willingness to achieve required internet speeds and comply with Work From Home specifications.

• Strong verbal and written communication skills.

• Capability to inspect handwritten and computer-generated documents as well as computer monitors.

• Ability to sit for extended periods, engage in telephone conversations, type, multitask, prioritize, and adapt to a fast-paced and changing environment.

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

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

• Preference will be given to candidates residing in EST time zones.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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