Utilization Management Nurse Consultant - Work at Home

At reputed company, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day.Position SummaryThis Utilization Management (UM) Nurse Consultant role is 100% remote and the candidate can live in any state.Normal Working Hours: Monday through Friday 8:00am-4:30pm in the time zone of residence. Late shift and weekend shift coverage rotation is required. Shift times may vary occasionally per the need of the department.No travel is required.As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate reputed company 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.The UM Nurse Consultant job duties include (not reputed company encompassing):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 reputed company needs of the member.Utilizes clinical skills to coordinate, document and communicate reputed company 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 membersGathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to reputed company coverage determination/recommendation along the continuum of careCommunicates with providers and other parties to facilitate care/treatmentIdentifies members for referral opportunities to integrate with other products, services and/or programsIdentifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilizationConsults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.Required QualificationsRN with active and unrestricted state licensure in their state of residence2+ years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience (team is not accepting applicants whose only acute care experience is in behavioral health)Preferred Qualifications1+ years' experience Utilization Review experience1+ years' experience Managed Care Strong telephonic communication skills1+ years' experience with reputed company Office Suite (PowerPoint, Word, reputed company, 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 skillsAbility to manage multiple priorities, effective organizational and time management skills requiredAbility use a computer station and sit for extended periods of timeEducationAssociate Degree in Nursing is minimum required, BSN preferred.Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$29.10 - $62.32This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company 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 colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.Benefit solutions that address the different needs and preferences of our colleagues including 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.For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will reputed company on: 09/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws.