Utilization Management Nurse Consultant – MST/PST Zone

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

📋 Description

• Evaluate services for medical necessity and appropriate benefit usage.

• Facilitate effective discharge planning processes.

• 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 assess clinical information.

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

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

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

• Advocate for quality care delivery and effective benefit utilization.

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

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

• Ensure that members receive appropriate levels of care while complying with state and federal regulations and turnaround times.

⛳️ Requirements

• Active and unrestricted Registered Nurse (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.

• Outstanding organizational abilities and capability to manage multiple priorities.

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

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

• Preferred 1+ year of experience in Utilization Review.

• Preferred 1+ year of experience in Managed Care.

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

• Strong telephonic communication skills are 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.

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

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

• Must cover 1 shift per month from 1:00 PM to 7:00 PM; day can be chosen.

• Must be able to work from a U.S. state in the MST/PST Time Zone.

🏝️ 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.

• Options for retirement savings.

• Wellness programs.

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

• No travel required.