Remote RN: Medicare Utilization & Quality Consultant

CVS Health; Virginia Beach (VA); Remote; USD 36,000 - 95,000; Full time

Job summary

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant. The role involves applying clinical judgment to determine coverage and coordinating care with providers to facilitate appropriate health services.

Required RN licensure in the resident state, ~3+ years RN experience, and ~1+ years Med/Surg. Strong communication and MS Office skills are essential. Remote work from home with strict HIPAA guidelines is supported.

Qualifications

• ~3+ years of experience as a Registered Nurse (RN).
• 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).

Responsibilities

• Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gather clinical information and apply criteria, policy and clinical judgment to render coverage determinations/recommendations.
• Communicate with providers and other parties to facilitate care/treatment.
• Identify members for referral opportunities to integrate with other products, services and/or programs.
• Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Consult and lend expertise to internal/external constituents in utilization/benefit management.

Skills

Clinical nursing experience

Care coordination

Communication skills

Education

Associates degree

BSN preferred

Tools

Microsoft Office

Job description

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant. The role involves applying clinical judgment to determine coverage and coordinating care with providers to facilitate appropriate health services.

Required RN licensure in the resident state, ~3+ years RN experience, and ~1+ years Med/Surg. Strong communication and MS Office skills are essential. Remote work from home with strict HIPAA guidelines is supported.