Utilization Management Nurse Consultant – Medical Review

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

📋 Description

• Execute, coordinate, monitor, and assess medical review cases by utilizing clinical expertise and skills.

• Employ clinical criteria, guidelines, plain language, and policy specifics to provide medical determinations to clients.

• Utilize critical thinking, evidence-based clinical criteria, and clinical practice guidelines.

• Authorize procedures/services or initiate Medical Director referrals as necessary.

• Support management in training new nurse reviewers, business partners, or vendors through initial and ongoing mentoring and feedback.

• Cross-train to conduct reviews across various case types.

• Suggest, evaluate, and implement enhancements in processes, audits, and technologies.

• Operate independently to achieve quality and metric standards.

• Collaborate with providers to ensure members receive timely and medically necessary care.

⛳️ Requirements

• Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges.

• Capability to obtain licensure in non-compact states as required.

• Minimum of 3 years of clinical experience.

• At least 5 years demonstrating the ability to make thorough independent decisions using clinical judgment.

• 5 years of proficient experience with equipment, including phones, computers, etc., and clinical documentation systems.

• 1+ year of experience in Utilization Review Management and/or Medical Management.

• Willingness to participate in a mandatory 3-week training from Monday to Friday, 8:30 am to 5:00 pm EST, with 100% attendance required.

• Preferred experience in interpreting Plan Language, Policies, and Benefits to assess medical necessity.

• Preferred experience with MCG Milliman, CPB, or other criteria guideline applications.

• An Associate's degree in nursing (RN) is required.

• A BSN is preferred.

• A dedicated workspace free of interruptions is essential.

• Dependents must have alternative care arrangements during work hours.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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