Utilization Management Nurse Consultant
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Job Description
CVS Health Utilization Management RN reviewing clinical information and supporting coverage determinations. Coordinating care and improving healthcare outcomes from home.
Responsibilities:
- Review clinical information and apply evidence-based guidelines, policies, and clinical judgment to support coverage determinations
- Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care
- Collaborate with providers and care teams to facilitate appropriate treatment and care planning
- Identify opportunities to improve quality of care, member outcomes, and healthcare utilization
- Connect members with additional programs, services, and resources when appropriate
- Serve as a clinical resource for internal and external stakeholders
- Work remotely in a computer-based role with productivity and quality expectations
- Collaborate frequently with providers, members, and interdisciplinary healthcare teams
- Work schedules that may include evenings, weekends, and holidays because Utilization Management operates 24/7
Requirements:
- Active, unrestricted RN license in your state of residence
- 2+ years of adult acute care and/or critical care nursing experience
- Strong clinical assessment, critical thinking, and communication skills
- Ability to multitask and work effectively in a fast-paced environment
- Proficiency navigating multiple computer systems and applications
- Associate Degree in Nursing required
- 2+ years of Med-Surg or specialty nursing experience preferred
- Managed Care or Utilization Management experience preferred
- Residence in the Central Time Zone preferred
- BSN preferred
- Availability for schedules that may include evenings, weekends, and holidays
- 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 virtual work location compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently living
- Ability to provide workspace furniture, such as a desk or standing desk
- Ability to use multiple monitors and applications simultaneously
- 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 log in to secure systems such as VPN and EHR portals
- Ability to follow computer, password, and security practices
- Ability to resolve common technical issues independently
- Openness to learning new skills as the workplace environment evolves
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 colleagues’ and families’ physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
- Remote work from home
- Collaborative clinical team environment
- Career growth in Utilization Management and Managed Care
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