Utilization Management Nurse Consultant; live in Pacific Time Zone

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.

This Utilization Management (UM) Nurse Consultant role is fully remote but must reside in PST zone.

• Monday through Friday between 8am-5pm PST.
• There is a weekend shift requirement (Saturday and Sunday both) per the needs of the team.
• Holiday rotation per the need of the department (typically 1 holiday per year).

There is no travel expected with this position.

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn‑around times. This includes reviewing written clinical records.

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• 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 reside in PST zone.
• RN with active and unrestricted state licensure in state of residence.
• 3+ years of clinical experience as an RN preferably in the following areas:
  Med/Surg, Telemetry, ICU, NICU, Long term care, cardiology.

• 1+ years’ experience in either Precertification or Utilization Review.
• 1+ years’ experience Managed Care.
• Strong telephonic communication skills.
• 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook).
• Experience with computers toggling between screens while using a keyboard and speaking to customers.
• Ability to exercise independent and sound judgment, strong decision‑making skills, and well‑developed interpersonal skills.
• Ability to manage multiple priorities, effective organizational and time‑management skills required.
• Ability to use a computer station and sit for extended periods of time.

• Associates Degree in Nursing required, BSN preferred.

40

Full time

The typical pay range for this role is:

$29.10 – $68.55

This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every…