Utilization Management Nurse Consultant
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Job Description
CVS Health utilization management nurse reviewing Medicare complex-spine cases and making evidence-based coverage decisions. Coordinating treatment with providers to improve member care quality and outcomes.
Responsibilities:
- Review clinical cases and make coverage determinations using evidence-based guidelines
- Collaborate with providers and care teams to coordinate appropriate treatment
- Apply clinical judgment to utilization and benefit management decisions
- Identify opportunities to improve care quality and member outcomes
- Serve as a clinical resource across internal and external stakeholders
- Transition clinical skills into a collaborative, non-bedside role focused on care coordination and healthcare quality
Requirements:
- Active, unrestricted RN license in the state of residence
- 3+ years of RN experience, including 1+ year in Med/Surg
- Strong clinical assessment and decision-making skills
- Experience with Microsoft Office (Outlook, Teams, Excel)
- Ability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone; schedules may include holidays and evening hours
- Associate Degree in Nursing
- Ability to obtain a 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 residing
- Must provide workspace furniture, such as a desk or standing desk
- Comfortable setting up and using multiple monitors and navigating multiple applications
- Ability to use 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 security practices, including locking screens, managing strong passwords, and recognizing suspicious emails or links
- Ability to resolve common technical issues independently and contact IT for unresolved issues
- Openness to learning new skills as the workplace 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 physical, emotional, and financial well-being
- Company-provided equipment including keyboard, monitor, computer, and headset
- Remote work from home
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