Utilization Management Nurse Consultant; EST

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

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.

Typical office working environment with productivity and quality expectations.

Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

Sedentary work involving periods of sitting, talking, listening.

Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

Effective communication skills, both verbal and written

• Candidate must reside in EST zones
• Candidate must have active and unrestricted Registered Nurse (RN) license in their state of residence
• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting
• Candidate must be available to work weekends, holidays, and evening hours as required by business needs

• 2+ years of clinical experience required in med surg or specialty area
• Managed care experience, especially Utilization Management

• Associates Degree in Nursing (REQUIRED)
• Bachelors Degree in Nursing (PREFERRED)

• Active and unrestricted Registered Nurse (RN) license in their state of residence

• 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…