[Hiring] Utilization Management Nurse Consultant @CVS Health

Role Description

Utilization Management is a 24/7 operation and work schedule may include weekends, holidays, and evening hours.

UM Nurse Consultant utilizes clinical experience and skills in a collaborative process to:

• Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicate with providers and other parties to facilitate care/treatment.
• Identify members for referral opportunities to integrate with other products, services, and/or programs.
• Identify opportunities to promote quality 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.

Qualifications

• Must have 3+ years of Med Surg experience as an RN in the hospital setting.
• Active and unrestricted RN licensure in state of residence.
• Able to work in multiple IT platforms/systems.
• 1+ years of experience with Microsoft Office Applications (Outlook, Teams, Excel).

Requirements

• Associates Degree in Nursing required.
• BSN preferred.
• Work from Home Requirements:
• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
• Technical and Logistical Requirements:
• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently, such as restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.