Utilization Management Nurse Consultant

This is a fully remote position, open to applicants in Texas, +1 more state.

📋 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 professional judgment to make coverage determinations or recommendations.

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

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

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

• Consult with and offer expertise to both internal and external stakeholders regarding utilization and benefit management.

• Operate in a standard office setting with expectations for productivity and quality.

• Conduct thorough inspections of handwritten and computer-generated documents and PC monitors.

• Remain seated for extended durations, engage in telephone conversations, and type on a computer.

• Effectively multitask, prioritize, and adapt to a dynamic, fast-paced environment.

⛳️ Requirements

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

• Active, current, and unrestricted RN licensure in the resident state.

• Must reside in the Eastern or Central Standard Time zone.

• An Associate's Degree is required.

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

• Capability to use multiple monitors and applications simultaneously.

• Proficient in communicating through email, calendar invites, Teams messaging, and virtual meetings.

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

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

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

• Ability to independently resolve common technical issues.

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

• Minimum internet speed of 50 Mbps for downloads and 5 Mbps for uploads.

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

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

• BSN is preferred.

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

🏝️ Benefits

• Equipment provided by the company (keyboard, monitor, computer, headset, etc.).

• Dental coverage.

• Vision coverage.

• Access to wellness resources.

• Employee discounts.

• Availability of certain voluntary benefits.

• Additional programs that support colleagues’ physical, emotional, and financial well-being.