Utilization Management Nurse Consultant

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🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

💼 Consultant

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Review clinical information and apply evidence-based criteria to make coverage recommendations • Collaborate with providers and interdisciplinary teams to support member care • Identify opportunities to improve healthcare quality, outcomes, and benefit utilization • Coordinate referrals to additional programs and services that support member needs • Serve as a clinical resource for internal and external stakeholders • Leverage clinical expertise to assess medical necessity, coordinate care, and ensure members receive appropriate healthcare benefits • Work in a 24/7 operation with schedules that may include evenings, weekends, and holidays

🎯 Requirements

• Active, unrestricted RN license in your state of residence • 2+ years of RN experience in adult acute care, critical care, medical-surgical, or specialty settings • Strong clinical judgment, communication, and multitasking skills • Ability to work efficiently across multiple computer systems in a productivity-driven environment • Associate’s Degree in Nursing • Direct/hardwired internet connection to a modem/router within 7 feet of the computer • Minimum internet speed of 25 Mbps download and 3 Mbps upload • WiFi and satellite internet are not permitted • Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines • Ability to work within the state and city where currently living • Ability to set up and use multiple monitors and navigate multiple applications simultaneously • Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings • Experience with Microsoft Office 365 applications or similar Google Workspace applications • Ability to log in to secure systems such as VPN and EHR portals • Ability to lock computer screens when unattended, manage strong passwords, and recognize suspicious emails or links • Ability to resolve common technical issues independently and contact IT for unresolved issues • Openness to learning new skills as the workplace evolves • BSN preferred • Utilization Management or Managed Care experience preferred • Residence in the Eastern Time Zone preferred

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • Company-provided equipment including keyboard, monitor, computer, and headset • Remote work arrangement