Utilization Management Nurse Consultant

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

📋 Description

• Evaluate services to ensure medical necessity and appropriate utilization of benefits.

• Facilitate effective discharge planning.

• Collaborate with healthcare providers and facilities to assist members with complex needs.

• Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.

• Gather and analyze clinical information.

• Utilize clinical criteria, guidelines, policies, and professional judgment to make coverage decisions.

• Communicate with providers and external partners to synchronize care and treatment strategies.

• Identify potential referrals to additional programs, services, or care solutions.

• Advocate for quality care delivery and efficient benefit utilization.

• Act as a resource for both internal and external stakeholders regarding utilization management processes and clinical considerations.

• Coordinate, document, and relay all facets of the utilization and benefit management process.

• Ensure members receive suitable care while complying with state and federal regulations and turnaround times.

⛳️ Requirements

• Current, unrestricted RN license.

• Minimum of 2 years of clinical experience in an acute hospital setting.

• Strong preference for experience in medical-surgical, ICU, behavioral health, or another specialty area.

• Excellent clinical assessment and decision-making skills.

• Strong organizational abilities and capacity to manage multiple priorities.

• Capability to work independently and communicate effectively by phone.

• Comfortable with computer-based tasks, multitasking across multiple screens, and documenting while on calls.

• Preferred experience of at least 1 year in Utilization Review.

• Preferred experience of at least 1 year in Managed Care.

• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) preferred.

• Strong telephonic communication skills preferred.

• Proven ability to exercise sound judgment and collaborate with diverse teams.

• Associate Degree in Nursing (ADN) is required.

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

• Must be able to work within the EST or CST time zones.

• Availability to work Monday through Friday from 8:00 AM to 5:00 PM, with a shift from 10:00 AM to 7:00 PM required once a month.

• Must include 12 weekends per year and rotating holidays (one minor and one major holiday per year).

🏝️ Benefits

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Resources supporting physical, emotional, and financial well-being.

• Comprehensive full-time benefits package.