Utilization Management Nurse Consultant

UM Nurse Consultant

Fully Remote- WFH

Schedule:

Tuesday-Saturday 9:30am-6:00pm

Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. The 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. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.

Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

-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)

- Knowledge of Medicare/Medicaid

- Managed care experience

- Utilization Management experience

Associates Degree required

BSN preferred

• 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.

• 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

40

Full time

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within…