Utilization Management Nurse Consultant

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🕒 August 4

🔔 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

• Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members • Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations or recommendations • Communicate with providers and other parties to facilitate care and treatment • Identify members for referral opportunities involving other products, services, and programs • Identify opportunities to promote healthcare service quality and effective benefit utilization • Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management • Work within a 24/7 operation that includes weekends, holidays, and evening hours • Perform work involving document and computer-monitor inspection, telephone communication, typing, multitasking, and navigating multiple computer systems

🎯 Requirements

• 2+ years of experience as a Registered Nurse in an adult acute care or critical care setting • Active, current, and unrestricted RN licensure in the state of residence • 2+ years of clinical experience in a medical-surgical or specialty area • Managed Care experience preferred, especially Utilization Management • Preference for candidates residing in Eastern Time zones • Associate’s degree required • BSN preferred • Proficiency with computer skills, including navigating multiple systems and keyboarding • Effective verbal and written communication skills • Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment • Availability for weekends, holidays, and evening hours in a 24/7 operation

🏖️ 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