Utilization Management Nurse Consultant

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🔥 0 minutes ago

🏈 Alabama, Arizona, +32 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🎰 Nevada – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🍑 Georgia – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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• Just posted.
• Jobs at this company usually fill in 21 days.

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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

• Conduct utilization management and prior authorization reviews • Ensure members receive medically appropriate, cost-effective care based on clinical guidelines and benefit plans • Review cases and make coverage determinations • Apply clinical expertise and critical thinking in a non-bedside role • Collaborate with providers and interdisciplinary teams • Support care coordination and high-quality healthcare outcomes • Work remotely from a designated home workspace while complying with CVS Health and HIPAA requirements

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license in the state of residence • Associate Degree in Nursing (ADN) or higher • Minimum of 3 years of clinical RN experience • At least 1 year of Medical-Surgical (Med/Surg) nursing experience • Strong clinical assessment, analytical, and decision-making skills • Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel • Ability to work Monday through Friday from 9:00 AM to 6:00 PM EST • Flexibility to support a 24/7 Utilization Management operation, including occasional holidays, evening hours, and schedule adjustments • Direct/hardwired internet connection with minimum 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted • Quiet, secure, private, HIPAA-compliant designated home workspace • Ability to use multiple monitors and navigate multiple applications • Ability to use email, calendar invites, Teams messaging, and virtual meetings • Experience with Microsoft Office 365 or similar Google Workspace applications • Ability to access secure systems such as VPN and EHR portals and follow computer and password security practices • Ability to troubleshoot common technical issues independently • Preferred: Knowledge of Medicare guidelines, medical necessity criteria, and evidence-based review processes • Preferred: Previous Utilization Management, Prior Authorization, or Concurrent Review experience • Preferred: Managed care, health plan, or payer-side clinical experience • Preferred: Experience using MedCompass or similar utilization management platforms • Preferred: Ambulatory surgery, procedural, or perioperative nursing experience • Preferred: Bachelor of Science in Nursing (BSN) • Preferred: Experience collaborating with physicians, providers, and interdisciplinary healthcare teams

🏖️ 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, headset, etc.

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