Utilization Management Nurse Consultant

Job Description:

• Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members
• Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations
• Communicate with providers and other parties to facilitate care and treatment
• Identify members for referral opportunities involving other products, services, or programs
• Identify opportunities to promote healthcare service quality and effective benefit utilization
• Consult with and provide expertise to internal and external constituents regarding utilization and benefit management
• Work in a typical office environment with productivity and quality expectations
• Perform close inspection of handwritten and computer-generated documents and PC monitors
• Sit for extended periods, talk on the telephone, and type on a computer
• Multitask, prioritize, and adapt to a fast-paced, changing environment

Requirements:

• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting
• Active, current, and unrestricted RN licensure in state of residence
• Availability to work weekends, holidays, and evening hours in a 24/7 operation
• Associates Degree required
• 2+ years of clinical experience in med surg or specialty area
• Managed Care experience preferred, especially Utilization Management
• Preference for residing in the Eastern Standard Time zone
• Direct/hardwired internet connection to a modem/router within 7 feet of the computer
• Minimum internet speed of 25 Mbps download and 3 Mbps upload
• Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
• Ability to work within the state and city where currently living
• Ability to use multiple monitors and navigate multiple applications
• Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
• Experience with Microsoft Office 365 applications or similar Google Workspace applications
• Ability to access secure systems such as VPN and EHR portals
• Ability to follow computer and password security practices and recognize suspicious emails or links
• Ability to troubleshoot common technical issues independently
• Effective verbal and written communication skills
• Computer proficiency, including keyboarding and navigation of multiple systems

Benefits:

• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being
• Company-provided equipment (keyboard, monitor, computer, headset, etc.)