Utilization Management Nurse Consultant (Remote, EST/CST)

Position Summary

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours (approximately 12 weekend days/year, one evening shift/month and 1 major and 1 minor holiday/year)

• 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.
• Typical office working environment with productivity and quality expectations.
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written

Required Qualifications

• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting
• Must have active current and unrestricted RN licensure in state of residence
• Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours

(Required) Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.

• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.

• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).

• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.

• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.

• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

(Required) Work from Home Requirements

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 50 Mbps download and 5 Mbps upload. WiFi and satellite internet are not permitted.

• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.

• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.

• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).

• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Preferred Qualifications

• 2+ years of clinical experience required in med surg or specialty area
• Managed Care experience preferred, especially Utilization Management
• Preference for those residing in EST zones

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