Remote Utilization Management Nurse Consultant

CVS Health Corporation; United States; Remote; USD 36,000 - 77,000; Full time

Job summary

CVS Health Corporation is seeking a Utilization Management Nurse Consultant to apply clinical judgment in determining appropriate care and benefit coverage. This full-time role requires RN licensure, 2+ years of hospital experience, and readiness for 24/7 scheduling including weekends and evenings.

The position involves collaborating with providers and teams to coordinate care, identify referral opportunities, and promote efficient use of services while maintaining HIPAA compliance.

Qualifications

• 2+ years of clinical experience as a Registered Nurse in a hospital setting in adult acute care/critical care setting.
• Must have active current and unrestricted RN licensure in state of residence.
• Utilization Management is a 24/7 operation and work schedules will include weekends, holidays and evening hours.
• 3+ years of clinical experience required in adult med surg or specialty area.
• Managed Care experience preferred, especially Utilization Management.
• Preference for those residing in CST zone.

Responsibilities

• 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.
• Typical office working environment with productivity and quality expectations.
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written.

Skills

RN experience

Clinical judgment

Communication skills

EHR systems

HIPAA compliance

Education

RN license

BSN preferred

Job description

CVS Health Corporation is seeking a Utilization Management Nurse Consultant to apply clinical judgment in determining appropriate care and benefit coverage. This full-time role requires RN licensure, 2+ years of hospital experience, and readiness for 24/7 scheduling including weekends and evenings.

The position involves collaborating with providers and teams to coordinate care, identify referral opportunities, and promote efficient use of services while maintaining HIPAA compliance.