Utilization Management Nurse Consultant – MST/PST Zone

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

📋 Description

• Evaluate services to determine medical necessity and appropriate benefit application.

• Assist in effective discharge planning.

• Work collaboratively with providers and facilities to aid members with complex requirements.

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

• Gather and assess clinical data utilizing clinical criteria, guidelines, policies, and judgment to make coverage decisions.

• Communicate with providers and external partners to ensure coordinated care and treatment plans.

• Identify referrals to additional programs, services, or care options.

• Advocate for high-quality care delivery and efficient benefit utilization.

• Act as a resource for internal and external stakeholders regarding UM processes and clinical considerations.

• Organize, document, and communicate utilization and benefit management activities while adhering to state and federal regulations and turnaround times.

⛳️ Requirements

• Valid, 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 and capability to manage multiple tasks.

• Ability to work independently and communicate effectively over the phone.

• Comfort with computer-based tasks, multitasking across several screens, and documenting during calls.

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

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

• Preferred proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook).

• Preferred strong telephonic communication abilities.

• Proven sound judgment and ability to work collaboratively with diverse teams.

• Associate Degree in Nursing (ADN) is required.

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

• Availability for Monday–Friday, 8:00 AM–5:00 PM CST.

• Required: weekends (12 per year) and holidays (1 minor and 1 major per year).

• One shift from 1:00 PM–7:00 PM per month, with the option to choose the day.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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