Utilization Management Nurse Consultant

A Utilization Management Nurse Consultant is responsible for evaluating and coordinating medical services to ensure patients receive appropriate, cost-effective care while adhering to clinical guidelines and organizational policies. This role involves assessing medical necessity, managing healthcare resources, and collaborating with healthcare providers to optimize patient outcomes.

Key Responsibilities:

• Conducting reviews of medical records to determine the appropriateness of healthcare services.
• Evaluating authorization requests against clinical guidelines and organizational policies.
• Collaborating with physicians, patients, and care teams to recommend alternative care solutions when necessary.
• Ensuring compliance with regulatory requirements and industry standards.
• Providing education and support to healthcare providers regarding utilization review processes.

Qualifications:

• Active Registered Nurse (RN) license.
• Experience in utilization management, case management, or clinical nursing.
• Strong analytical and decision-making skills.
• Familiarity with healthcare regulations, insurance plans, and medical necessity criteria (e.g., InterQual, MCG).
• Excellent communication and organizational abilities.

This position typically offers remote flexibility, competitive benefits, and opportunities for career growth in the healthcare industry. It is ideal for experienced nurses looking to transition into a consultative and administrative role while continuing to impact patient care.

Job description

About the position

The Utilization Management Nurse Consultant role at CVS Health is a fully remote position focused on coordinating and managing healthcare services for members. The consultant will work primarily in a clinical telephone queue, collaborating with providers to secure necessary information for prior authorization reviews. This position requires strong clinical judgment and the ability to assess, plan, implement, and evaluate healthcare options effectively. The role emphasizes the importance of communication and collaboration in facilitating appropriate healthcare services and benefits for members.

Responsibilities
• Work in a clinical telephone queue for 4 to 6 hours a day with providers to secure additional information for prior authorization review.
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• Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
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• Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
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• Gather clinical information and apply appropriate clinical criteria/guidelines to render determinations/recommendations along the continuum of care.
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• Communicate with providers and other parties to facilitate care/treatment.
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• Identify members for referral opportunities to integrate with other products, services, and/or programs.
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• Promote quality effectiveness of healthcare services and benefit utilization.
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• Consult and lend expertise to internal and external constituents in the coordination and administration of the utilization/benefit management function.

Requirements
• 5 years of a variety of clinical experience including acute care, home health, or long-term care.
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• 5 years demonstrated ability to make thorough, independent decisions using clinical judgment.
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• A Registered Nurse with an unrestricted license in their state of residence, with multi-state/compact privileges.
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• Ability to be licensed in all noncompact states.
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• Required to use a residential broadband service with internet speeds of at least 25 mbps/3mbps.

Nice-to-haves
• 1 year of varied UM (utilization management) experience within an inpatient/outpatient setting, concurrent review or prior authorization.
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• 1+ years Managed Care (MCO) experience preferred.
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• 1+ years demonstrated experience working in a high-volume clinical call center environment.
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• Remote work experience.

Benefits
• 401(k)
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• Dental insurance
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• Disability insurance
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• Employee discount
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• Employee stock purchase plan
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• Health insurance
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• Life insurance
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• Paid Time Off (PTO)
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• Paid holidays
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• Short-term and long-term disability benefits
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• Well-being programs
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• Education assistance
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• Free development courses