Utilization Management Nurse Consultant - Work At Home - EST Zone

At CVS Health, 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 reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position Title: Utilization Management Nurse (RN)
Position Summary:

This role supports a 24/7 Utilization Management operation, which includes coverage during evenings, weekends, and holidays.

The Utilization Management Nurse applies clinical expertise in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits for members. The nurse uses clinical judgment and established guidelines to make coverage determinations and ensure appropriate care across the continuum.
Key Responsibilities:

• Gather and evaluate clinical information to determine medical necessity and benefit coverage using established criteria, policies, and procedures.
• Communicate with providers and care teams to coordinate treatment and facilitate appropriate care.
• Identify members for referral to additional programs, services, or resources.
• Promote quality care and effective utilization of healthcare services.
• Serve as a clinical resource and consultant to internal and external stakeholders.
• Maintain accurate and timely documentation in electronic systems.
• Work in a typical office environment with expectations for productivity and quality.
• Perform sedentary work involving extended periods of sitting, computer use, and phone communication.
• Effectively multitask, prioritize, and adapt in a fast-paced, dynamic environment.
• Navigate multiple systems and demonstrate strong computer proficiency.
• Communicate clearly and professionally, both verbally and in writing.

• Active, unrestricted Registered Nurse (RN) license in state of residence.
• Minimum 2 years of RN experience in an adult acute care or critical care setting.
• Availability to work evenings, weekends, and holidays as part of a 24/7 operation.

• 2+ years of clinical experience in medical-surgical or specialty areas.
• Managed care experience, particularly in Utilization Management.
• Preference for candidates residing in Eastern Time Zone (EST).

• Associate Degree in Nursing required.
• Bachelor of Science in Nursing (BSN) preferred.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all 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.