Utilization Management Nurse Consultant
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Job Description
Utilization Management Nurse Consultant coordinating clinical coverage decisions and care services for CVS Health members. Remote Pennsylvania role supporting a 24/7 healthcare operation.
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, 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.)
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