Utilization Management Nurse Consultant

4062 Aetna Resources, LLC; North Carolina; Hybrid; USD 36,000 - 94,000; Full time

Benefits offered by this job

Bonus eligibility

Comprehensive benefits package

Paid time off

Job summary

CVS Health is seeking a Registered Nurse to join our Utilization Management team in a work-from-home weekend position. You will assess, plan, and coordinate care, applying clinical criteria to determine appropriate benefits and services for members.

The role requires 3+ years RN experience, 1+ year in UM/Care Management, and active RN licensure. You will collaborate with providers, monitor outcomes, and ensure high-quality, cost-effective care while meeting productivity standards in a fast-paced

Qualifications

• Active RN license in state of residence.
• ≥3 years of RN experience.
• ≥1 year in Utilization Management / Care Management.
• May require additional nursing licenses as needed.

Responsibilities

• Render coverage determinations and recommendations along the care continuum.
• Communicate with providers and other parties to facilitate care.
• Identify referral opportunities to integrate with products, services, or benefits.
• Promote quality and effectiveness of healthcare services and utilization.
• Meet productivity and quality expectations per UMNC.

Skills

Communication skills

Computer skills

Multitasking

Endurance (sitting)

Education

RN Diploma or degree

BSN/Associates preferred

Job description

We’re building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Schedule:

This is an Alternative Work Schedule weekend position. The role requires coverage of both Saturday and Sunday each week. Scheduling options may include four 10-hour shifts, five 8-hour shifts, three 12-hour shifts, or other approved configurations that meet operational needs. Specific schedules will be determined in collaboration with management to ensure adequate weekend coverage.

Position Summary:

Utilize your clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.

Key Responsibilities:

• Gather clinical information and apply the appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations and recommendations along the continuum of care.
• Communicate with providers and other parties to facilitate care and treatment. Identify members for referral opportunities to integrate with other products, services, or benefit programs.
• Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization.
• Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Meet set productivity and quality expectations as established by UMNC.

Required Skills and Abilities:

• Effective verbal and written communication skills.
• Proficiency with computer skills, including navigating multiple systems and keyboarding.
• Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment.
• Capacity to sit for extended periods, talk on the telephone, and type on the computer.

Work Location:

This is a work-from-home position. During work hours, colleagues must be available by phone, videoconference, and email as required by their leader. Occasional on-site attendance at the office or client location may be required for meetings, training sessions, or other events as directed.

Required Qualifications:

Registered Nurse Education: Diploma RN acceptable; Associate degree/BSN preferred, 3+ years of experience as a Registered Nurse, 1+ years of clinical experience in acute or post-acute setting, and 1+ years of Utilization Management / Care Management Experience Must have active current and unrestricted RN licensure in state of residence. May be required to obtain additional Nursing Licenses as business needs require.

Preferred Qualifications:

• Preferred Qualifications - Utilization Management experience preferred

Anticipated Weekly Hours

40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future.

Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience

is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.