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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours.

This will be a full-time remote role. Schedule is Monday through Friday, 8am to 5pm CST with required weekend, holiday and evening rotations.

Position Summary

Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification. The majority of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. This position will be working regular business hours with potential for occasional weekend/holiday on-call.

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

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Required Qualifications

Must have active, current, and unrestricted compact RN licensure in state of residence

3+ years of clinical experience required

1+ years of Microsoft Office Suite experience required

Preferred Qualifications

Prior Authorization experience strongly preferred

Sedentary work involves periods of sitting, talking, listening and computer use Ability to work in a fast paced environment

Freelance Utilization Management Nurse Consultant | CVS Health | Remote (United States) Job ID- 678

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