Utilization Management Nurse Consultant

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

📋 Description

• Perform utilization reviews and clinical assessments to determine the medical necessity, appropriateness, and efficiency of healthcare services.

• Utilize evidence-based criteria and clinical knowledge to inform decisions on benefits and utilization management.

• Evaluate medical records, treatment plans, and associated documentation for compliance standards.

• Develop, coordinate, and facilitate care plans in collaboration with providers, multidisciplinary teams, and payers.

• Prepare, audit, and oversee the management of approval and denial correspondence.

• Advocate for utilization management practices through consultation, education, and teamwork.

• Assist in care coordination efforts to enhance member outcomes and access to healthcare services.

• Engage with providers, members, and internal teams regarding decisions related to utilization management.

• Ensure comprehensive, accurate, and timely documentation is maintained.

• Offer guidance and coaching to nursing staff and other healthcare professionals.

• Contribute to the development of utilization management policies, procedures, and initiatives aimed at quality improvement.

• Foster quality, effectiveness, and efficiency of healthcare services throughout the care continuum.

⛳️ Requirements

• Valid Registered Nurse (RN) license.

• 3-5 years of relevant experience in clinical, case management, utilization management, or healthcare settings.

• Familiarity with medical terminology and healthcare delivery systems.

• Strong problem-solving and critical-thinking capabilities.

• Proven decision-making skills with demonstrated clinical judgment.

• Proficient in technology and digital tools commonly used in healthcare environments.

• Ability to evaluate costs and benefits of various approaches and suggest suitable solutions.

• Excellent interpersonal and communication skills.

• Capacity to maintain confidentiality and manage sensitive information in an ethical and responsible manner.

• Ability to work effectively in diverse clinical and cultural settings.

• Availability to work Thursday through Sunday, from 9:00 AM to 8:00 PM Eastern Time.

• Experience in utilization management, care management, managed care, or health plan operations is preferred.

• Understanding of regulatory, accreditation, and quality standards related to utilization management is preferred.

• Experience in reviewing medical necessity criteria and healthcare benefits is preferred.

• Bachelor's degree in Nursing, Healthcare Administration, or a related healthcare field is preferred.

• Equivalent specialized training, certification, or relevant professional experience may be considered as a substitute for a degree.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.