Utilization Mangement Nurse Consultant - Work at Home - CST

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About the position

The Utilization Management Nurse Consultant uses clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options that facilitate appropriate healthcare services and benefits for members. The role gathers clinical information and applies clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations across the continuum of care. It communicates with providers and other parties to facilitate care and treatment, identifies members for referrals to other products, services, or programs, and finds opportunities to promote quality, effective healthcare services and benefit utilization. The consultant also provides expertise to internal and external constituents in coordinating and administering utilization and benefit management. This is a work-from-home position for a resident of the Central Standard Time zone. The usual schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. CST, with 12 weekend shifts per year, occasional weekend shifts from 10:00 a.m. to 7:00 p.m., and two holidays per year; schedules are subject to change. Utilization Management operates 24/7, so work schedules may include weekends, holidays, and evening hours. The role involves a typical office working environment with productivity and quality expectations. Work is sedentary and includes extended periods of sitting, telephone conversations, listening, and computer typing. It requires close inspection of handwritten and computer-generated documents and a PC monitor, multitasking, prioritizing, adapting to a fast-paced changing environment, and navigating multiple computer systems. The company provides equipment such as a keyboard, monitor, computer, and headset; the employee provides workspace furniture. A direct wired internet connection meeting the stated speed requirements and a quiet, secure, private, designated home workspace that complies with CVS Health and HIPAA guidelines are required.

Responsibilities

  • Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.
  • Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations across the continuum of care.
  • Communicate with providers and other parties to facilitate care and treatment.
  • Identify members for referral opportunities to other products, services, and programs.
  • Identify opportunities to promote quality and effective healthcare services and benefit utilization.
  • Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management.

Requirements

  • At least 2 years of experience as a Registered Nurse in an adult acute care or critical care setting.
  • Active, current, unrestricted RN licensure in the state of residence.
  • Associate degree required.
  • Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
  • Ability to communicate using digital channels, including email, calendar invitations, Teams messaging, and virtual meetings.
  • Experience using Microsoft Office 365 applications or similar tools such as Google Workspace.
  • Ability to access secure systems, use basic security practices, and recognize suspicious emails or links.
  • Ability to resolve common technical issues independently and contact IT for unresolved issues.
  • Openness to learning new skills as the workplace environment evolves.
  • Ability to obtain and maintain a direct, hardwired internet connection to a modem or router within 7 feet of the computer, with a minimum speed of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
  • A quiet, secure, private, designated home workspace that is free from distractions, organized, compliant with CVS Health and HIPAA guidelines, and allows uninterrupted work.
  • Must work from within the state and city where currently residing.
  • Must provide workspace furniture, such as a desk or standing desk, and meet all work-from-home requirements.
  • Effective verbal and written communication skills.
  • Proficiency with computer skills, including navigating multiple systems and keyboarding.

Nice-to-haves

  • At least 2 years of clinical experience in a medical-surgical or specialty area.
  • Managed care experience, especially Utilization Management.
  • Residence in a Central Standard Time zone.
  • BSN.

Benefits

  • Medical coverage
  • Dental coverage
  • Vision coverage
  • Paid time off
  • Retirement savings options
  • Wellness programs
  • CVS Health bonus, commission, or short-term incentive program eligibility
  • Other resources to support colleagues and their families, based on eligibility
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