Remote Utilization Management Nurse (RN)

4062 Aetna Resources, LLC; Kansas; Remote; USD 35,831 - 77,338; Full time

Benefits offered by this job

Healthcare benefits

Bonus eligibility

Job summary

CVS Health is seeking a Utilization Management (UM) Nurse Consultant for a fully remote, full-time role open to CST zone candidates. You will coordinate, document, and communicate all aspects of utilization and benefit management, ensuring appropriate care levels within state and federal requirements and turnaround times.

Responsibilities include reviewing medical necessity, collaborating 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.

Job description

CVS Health is seeking a Utilization Management (UM) Nurse Consultant for a fully remote, full-time role open to CST zone candidates. You will coordinate, document, and communicate all aspects of utilization and benefit management, ensuring appropriate care levels within state and federal requirements and turnaround times.

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