Utilization Management Nurse Consultant

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

📋 Description

• Evaluate services for medical necessity and suitable benefit application

• Assist in effective discharge planning

• Work collaboratively with 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 judgment to make coverage decisions

• Communicate with providers and external partners to coordinate care and treatment strategies

• Identify opportunities for referrals to additional programs, services, or care solutions

• Enhance 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 communicate all facets of the utilization and benefit management process

• Ensure members receive the most appropriate level of care while adhering to state and federal requirements and turnaround times

⛳️ Requirements

• Active, unrestricted RN license

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

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

• Excellent clinical assessment and decision-making skills

• Exceptional organizational abilities with the capacity to manage multiple priorities

• Ability to work independently and communicate effectively via phone

• Proficiency with computer-based tasks, multitasking across multiple screens, and documenting during calls

• At least 1 year of Utilization Review experience preferred

• At least 1 year of Managed Care experience preferred

• 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 preferred

• Associate Degree in Nursing (ADN) required

• Bachelor of Science in Nursing (BSN) preferred

• Availability for a 10:00 AM–7:00 PM shift once a month

• Willingness to work 12 weekends per year

• Availability to work holidays, rotating one minor and one major holiday per year

• Candidates must reside in a U.S. state within the EST or CST Zones

🏝️ 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

• Additional resources supporting physical, emotional, and financial well-being, based on eligibility

• 100% remote work arrangement