CVS Health is looking for a Utilization Management Nurse Consultant to join our team. In this work-from-home role, you will apply critical thinking and clinical criteria to review and authorize services requiring precertification. You’ll gather clinical information, apply evidence-based guidelines, and communicate with providers to facilitate appropriate care for members.
What You’ll Do
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines for services requiring precertification.
- Collect and review clinical information from providers.
- Use specific criteria to authorize procedures or initiate a Medical Director referral as needed.
- Utilize clinical experience to assess, plan, coordinate, and evaluate options to facilitate appropriate healthcare services for members.
- Gather clinical information and apply the appropriate criteria, policy, and clinical judgment to render coverage determinations.
- Communicate with providers and other parties to facilitate care and treatment.
- Identify members for referral opportunities to integrate with other products, services, and 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 utilization and benefit management.
What We’re Looking For
- Must have an active, current, and unrestricted compact RN license in your state of residence.
- 3+ years of clinical experience.
- 1+ years of experience with Microsoft Office Suite.
- Proficiency with computer skills, including navigating multiple systems.
- Ability to work in a fast-paced environment.
- An Associate's degree is required.
- Effective communication skills, both verbal and written.
Nice to Have
- Prior Authorization experience.
- A BSN degree.
Technical Stack
- Microsoft Office Suite.
Benefits & Compensation
- Compensation: $26.01 - $56.14 per hour.
- Affordable medical plan options.
- 401(k) plan with matching company contributions.
- Employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation, weight management programs, confidential counseling, and financial coaching.
- Paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access, and many other benefits depending on eligibility.
Work Mode
This is a fully remote position.
CVS Health is committed to fostering a workplace where every colleague feels valued and that they belong. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
