Utilization Management Nurse Consultant

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

📋 Description

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

• Collect clinical information and apply 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 for referral opportunities related to other products, services, and programs.

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

• Consult with and offer expertise to both internal and external stakeholders in coordinating and managing utilization and benefit management.

• Operate within a 24/7 utilization management environment, which may include weekends, holidays, and evening hours.

• Conduct tasks that involve prolonged sitting, telephone communication, computer usage, and close examination of documents and screens.

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

⛳️ Requirements

• A minimum of 2 years of clinical experience as a Registered Nurse in a hospital setting, specifically in adult acute care/critical care.

• Active, valid, and unrestricted RN licensure in the state of residence.

• An Associate or Bachelor of Science in Nursing (BSN preferred).

• Preferred: At least 3 years of clinical experience in adult med-surg or a specialty area.

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

• Preference for candidates living in the CST time zone.

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

• Minimum internet speed of 25 Mbps for download and 3 Mbps for upload.

• WiFi and satellite internet connections are not permitted.

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

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

• Proficiency in navigating multiple systems and keyboarding.

• Strong verbal and written communication skills.

• Experience or capability to use Microsoft Office 365 or similar productivity applications.

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

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

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

• Willingness to learn new workplace skills.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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

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

• Flexible work-from-home arrangement.