Remote RN Utilization Management Consultant

CVS Health; Wyoming (MI); Remote; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant to assess and authorize appropriate healthcare services for members, coordinating with providers to ensure effective care and optimal utilization of benefits.

The role requires clinical judgment, collaboration, and experience with utilization management across care settings, with a focus on Medicare-related processes.

Qualifications

• 3+ years of experience as a Registered Nurse.
• Must have 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

• 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

RN experience

Med/Surg experience

Microsoft Office

Education

Associates degree

BSN

Tools

MedCompass

Job description

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant to assess and authorize appropriate healthcare services for members, coordinating with providers to ensure effective care and optimal utilization of benefits.

The role requires clinical judgment, collaboration, and experience with utilization management across care settings, with a focus on Medicare-related processes.