Utilization Management Nurse Consultant
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Job Description
CVS Health nurse consultant assessing Medicare coverage and utilization management decisions. Coordinating clinical reviews, provider communication, and member care referrals remotely.
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 healthcare service quality and benefit utilization
- Consult and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
- Work collaboratively within a 24/7 Utilization Management operation
Requirements:
- 3+ years of experience as a Registered Nurse
- Active, current and unrestricted RN licensure in state of residence
- 1+ years of Med/Surg experience
- 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
- Willingness and ability to work Monday through Friday, 9:00am to 5:30pm eastern or central time, with occasional holiday rotation
- Utilization Management schedules may include holidays and evening hours
- Prior Authorization or Utilization Management experience preferred
- Managed care experience preferred
- Experience using MedCompass preferred
- Ambulatory surgery experience preferred
- Associates degree required
- 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
- Must provide workspace furniture
- Ability to set up and use multiple monitors and navigate multiple applications
- Ability to communicate via email, calendar invites, Teams messaging and virtual meetings
- Experience with Microsoft Office 365 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
- Openness to learning new skills
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’ physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
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