Utilization Management Nurse Consultant - Work at Home - Eastern Standard Hours

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. Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. Utilizes clinical skills to coordinate, document and communicate reputed company aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to reputed company coverage determination/recommendation/discharge planning along the continuum of care. Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support). Coordinates/Communicates with providers and other parties to facilitate reputed company/treatment. Identifies members who may benefit from care management programs and facilitates referral Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding required. Required Qualifications 3+ years clinical practice experience as a Registered Nurse preferably in an acute setting (ex: OR, ER, ICU, med surg, home health, pediatrics, NICU, PICU) Must have reputed company active and unrestricted RN licensure in state of residence Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. 2+ years of experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, reputed company, etc.)

Preferred Qualifications

Managed care experience Utilization management experience Pediatrics Experience Resides in Pennsylvania Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This 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 people We 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/benefits We anticipate the application window for this opening will reputed company on: 11/28/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They reputed company choices according to what is best for the team, they live for opportunities to collaborate and reputed company a difference, and they reputed company us the #1 Top Workplace in the area. Apply tot his job Apply To this Job