Utilization Management Nurse Consultant

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

📋 Description

• Oversee, document, and communicate all elements of the utilization and benefit management program.

• Ensure that members receive the necessary care at the right time and location, while complying with federal and state mandated turnaround times.

• Review clinical records and services to validate medical necessity.

• Utilize clinical expertise, criteria, guidelines, policies, procedures, and clinical judgment to assess or recommend coverage.

• Support safe and efficient discharge planning processes.

• Collaborate with facilities, providers, and other stakeholders to address complex member needs and facilitate care.

• Evaluate, plan, implement, coordinate, monitor, and assess healthcare service and benefit options.

• Identify members for referral opportunities to various products, services, and programs.

• Recognize opportunities to enhance healthcare service quality and effective benefit utilization.

• Consult with both internal and external stakeholders regarding the coordination and administration of utilization and benefit management.

• Minimal travel may be required, potentially up to 10%, for clinical audits.

⛳️ Requirements

• Must hold an active, current, and unrestricted RN license in the state of residence.

• A minimum of 2 years of recent acute hospital clinical experience as an RN, specifically within the last 10 years.

• At least 1 year of experience with Microsoft Office applications, including PowerPoint, Excel, and Word.

• Willingness and availability to work Monday through Friday, from 8:00am to 4:30pm in the local time zone.

• Willingness and ability to participate in weekend and holiday rotations as needed by the department.

• An Associate Degree in Nursing is required.

• Experience in Utilization Review is preferred.

• A background in Managed Care is preferred.

• Strong telephonic communication skills are preferred.

• A Bachelor's Degree in Science & Nursing is preferred.

🏝️ Benefits

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

• Comprehensive medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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