Remote Utilization Management Nurse Consultant

CVS Health; Phoenix (AZ); On-site; USD 40,000 - 86,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking an experienced Utilization Management (UM) Nurse Consultant for a fully remote role available to MST/PST zone residents across the United States. You will coordinate, document, and communicate utilization and benefit management to ensure safe, effective care while meeting state and federal requirements.

Responsibilities include reviewing medical necessity, coordinating with providers, and supporting cost-effective care.

Qualifications

• Active, unrestricted RN license.
• 2+ years of acute hospital clinical experience.
• Strong clinical assessment and decision-making abilities.
• Excellent organizational skills with the ability to manage multiple priorities.
• Ability to work independently and communicate effectively via phone.
• Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls.

Responsibilities

• Reviewing services for medical necessity and appropriate benefit use, facilitating efficient discharge planning, and collaborating with providers and facilities to support members with complex needs.
• Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.
• Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations.
• Communicating with providers and external partners to coordinate care and treatment plans.
• Identifying opportunities for referrals to additional programs, services, or care solutions.
• Recognizing opportunities to promote quality care delivery and effective benefit utilization.
• Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.

Skills

RN license

Acute hospital experience

Clinical assessment

Organizational skills

Independent work

Phone communication

Computer-based work

Education

Associate Degree in Nursing

BSN preferred

Tools

Microsoft Office

Job description

CVS Health is seeking an experienced Utilization Management (UM) Nurse Consultant for a fully remote role available to MST/PST zone residents across the United States. You will coordinate, document, and communicate utilization and benefit management to ensure safe, effective care while meeting state and federal requirements.

Responsibilities include reviewing medical necessity, coordinating with providers, and supporting cost-effective care.