Remote Medicare Utilization Nurse Consultant

CVS Health; Clayton (NM); Remote; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant in the United States. The role runs Monday–Friday, 9:00am–5:30pm in the candidate’s time zone, with 24/7 utilization management scheduling including holidays and evenings.

You will assess and coordinate healthcare services, gather information, apply clinical criteria, and render coverage recommendations while collaborating with providers and internal teams.

Qualifications

• 3+ years RN experience required.
• Active, unrestricted RN license in state of residence.
• 1+ years Med/Surg experience.
• 1+ years Microsoft Office (Outlook, Teams, Excel).
• Preferred: Prior Authorization or Utilization Management experience.
• Preferred: Medicare experience.

Responsibilities

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Skills

Registered Nurse

Med/Surg experience

Microsoft Office

Outlook

Excel

Team collaboration

Utilization Management

Education

Associates degree

BSN preferred

Job description

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant in the United States. The role runs Monday–Friday, 9:00am–5:30pm in the candidate’s time zone, with 24/7 utilization management scheduling including holidays and evenings.

You will assess and coordinate healthcare services, gather information, apply clinical criteria, and render coverage recommendations while collaborating with providers and internal teams.