Utilization Management Nurse Consultant
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Job Description
Utilization Management Nurse Consultant assessing clinical information and coordinating healthcare coverage decisions for CVS Health members. Remote Illinois role supporting 24/7 utilization management operations.
Responsibilities:
- 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 and programs
- Identify opportunities to promote quality and effective healthcare services and benefit utilization
- Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
- Work within a 24/7 utilization management operation, including possible weekends, holidays and evening hours
- Perform work involving prolonged sitting, telephone communication, computer use and close inspection of documents and monitors
- Navigate multiple applications and systems while meeting productivity and quality expectations
Requirements:
- 2+ years of clinical experience as a Registered Nurse in a hospital setting in adult acute care/critical care
- Active, current and unrestricted RN licensure in state of residence
- Associate or Bachelor of Science in Nursing (BSN preferred)
- Preferred: 3+ years of clinical experience in adult med surg or specialty area
- Managed Care experience preferred, especially Utilization Management
- Preference for candidates residing in the CST zone
- Direct/hardwired internet connection to modem/router within 7 feet of computer
- Minimum internet speed of 25 Mbps download and 3 Mbps upload
- WiFi and satellite internet are not permitted
- Quiet, secure and private designated home workspace compliant with CVS Health and HIPAA guidelines
- Ability to work within the state and city where currently residing
- Proficiency navigating multiple systems and keyboarding
- Effective verbal and written communication skills
- Experience or ability to use Microsoft Office 365 or similar productivity applications
- Ability to use secure systems such as VPN and EHR portals
- Ability to manage strong passwords and recognize suspicious emails or links
- Ability to troubleshoot common technical issues and contact IT when necessary
- Openness to learning new workplace skills
Benefits:
- 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.)
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Flexible work-from-home arrangement
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