[Remote] Utilization Management Nurse Consultant at CVS Health

Michigan City, Mississippi, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

Active unrestricted state Registered Nurse licensure in state of residence
Associate's degree in nursing (RN) required, BSN preferred
Minimum 5 years of relevant experience in Nursing
At least 1 year of Utilization Management experience in concurrent review or prior authorization
Strong decision-making skills and clinical judgment in independent scenarios
Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms
Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation
Availability to work any 8-hour shift within 8:00 am-8:00 pm EST, with start times ranging from 8:00 am-11:30am EST
Dedicated workspace free of interruptions for 100% remote role; dependents must have separate care arrangements during work hours

Responsibilities

Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review
Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information
Use established guidelines to authorize services or escalate to Medical Directors as needed
Navigate multiple computer systems efficiently while maintaining accurate documentation
Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills
Perform sedentary work involving extended periods of sitting, frequent talking, listening, and use of a computer
Provide flexibility to cover for other Utilization Management (UM) Nurses across various UM specialty teams as needed
Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements

Skills

Key technologies and capabilities for this role

Utilization ManagementClinical ReviewEvidence-Based CriteriaCase ManagementNursingPrecertificationConcurrent ReviewMedical DocumentationProvider CollaborationURAC AccreditationCritical Thinking

Questions & Answers

Common questions about this position

Is this position remote?

Yes, this is a 100% remote role, but candidates must have a dedicated workspace free of interruptions and ensure dependents have separate care arrangements during work hours.

What are the required qualifications for this role?

Candidates need an active unrestricted state Registered Nurse licensure in their state of residence, a minimum of 5 years of relevant nursing experience, and at least 1 year of Utilization Management experience in concurrent review or prior authorization.

What are the work hours and schedule like?

Regular business hours are 8:00 am-8:00 pm EST, with availability required for any 8-hour shift starting between 8:00 am-11:30 am EST, plus occasional on-call rotations including weekends and holidays.

What skills are essential for success in this role?

Key skills include critical thinking, strong organizational and multitasking abilities, proficiency navigating multiple computer systems, and thriving in a fast-paced, high-volume environment.

What makes a strong candidate for this Nurse Consultant position?

Nurses who thrive in fast-paced environments, are highly organized, comfortable with computer-based work, and have experience in utilization management with the required licensure and years of experience stand out.

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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