Remote RN: Utilization & Care Coordination Specialist

CVS Health; Columbus (OH); On-site; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Benefits package

Job summary

CVS Health is seeking an Utilization Management Nurse Consultant to coordinate, document and communicate all aspects of the utilization/benefit management program. The role emphasizes reviewing records to ensure medical necessity and timely care within regulatory guidelines.

Requires active RN license, 3+ years RN experience, and 1+ year of MS Office use; remote work with a Mon-Fri 8:00am-4:30pm EST schedule, 40 hours weekly, plus occasional weekend/holiday rotations.

Qualifications

• Must have active, current, and unrestricted RN licensure in state of residence
• 3+ years of clinical RN experience
• 1+ years of experience using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)
• Must be available to work Monday through Friday 8:00am - 4:30pm EST
• Must be willing to work weekend rotation, approximately every 6 weeks
• Holiday rotation per the need of the department (typically 1 holiday per year)

Responsibilities

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• 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

Communication skills

Time management

Multitasking

Organizational skills

Education

Associate degree

BSN preferred

Tools

Microsoft Office Suite

Teams

Outlook

Word

Excel

Job description

CVS Health is seeking an Utilization Management Nurse Consultant to coordinate, document and communicate all aspects of the utilization/benefit management program. The role emphasizes reviewing records to ensure medical necessity and timely care within regulatory guidelines.

Requires active RN license, 3+ years RN experience, and 1+ year of MS Office use; remote work with a Mon-Fri 8:00am-4:30pm EST schedule, 40 hours weekly, plus occasional weekend/holiday rotations.