Utilization Management Nurse Consultant - Work at Home

At reputed company, 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 reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Position Summary This Utilization Management (UM) Nurse Consultant role is 100% work at home and the candidate can live in any state. Work At Home Requirements: Candidate will work from home (WAH) out of their residence. Have reliable phone and hard-wired internet service. Work schedules are determined by the Leader based on business needs and are not affected by the work model or location. Mon – Fri 8:30-5:00 PM in your time zone. Shift times may vary per business need as well as there being a Rotational late shift 9:30-6:00 PM CST time zone. Colleagues must be reachable reputed company phone, videoconference, and email during work hours (8 Hours per Day) as directed by their Leader. Personal responsibilities, including dependent care, must not interfere with work duties. Dependent care during work hours is generally not allowed. Be secure and private to maintain confidentiality (HIPAA compliant). Meet any additional reasonable requirements set by the Leader or Company. Sedentary position must be reputed company to sit for long periods of time. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate reputed company aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. The UM Nurse Consultant job duties include (not reputed company encompassing): Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the reputed company needs of the member. Utilizes clinical skills to coordinate, document and communicate reputed company aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate reputed company services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to reputed company 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 reputed company 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. Required Qualifications: RN with active and unrestricted state licensure in their state of residence 2 or more years of acute hospital clinical experience as an RN with preference for medical-surgical and ICU experience Technical Skills Required: Proficient in Multisystem Navigation: Comfortable using multiple monitors and systems simultaneously to streamline tasks and improve efficiency. Effective Multitasker: Skilled at talking and typing concurrently while managing various responsibilities with focus and accuracy. Basic Technical Troubleshooting: reputed company to set up and connect essential hardware (monitors, keyboards, etc.) and resolve common technical issues independently. Digital Collaboration & Documentation: reputed company in electronic documentation and virtual collaboration tools to support remote teamwork and communication. Highly Organized & Results-Oriented: Maintains a structured approach to work, ensuring tasks are completed on time and in alignment with performance metrics. Metric-Driven Performance: Demonstrates accountability by consistently meeting or exceeding established goals and expectations. Preferred Qualifications: 1 or more years’ experience Utilization Review experience 1 or more years’ experience Managed Care Strong telephonic communication skills 1 or more years’ experience with reputed company Office Suite (PowerPoint, Word, reputed company, Outlook) Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills Ability to manage multiple priorities, effective organizational and time management skills required Education Requirements: Associate Degree in Nursing is minimum 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 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for reputed company 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. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 12/05/2025 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They reputed company choices according to what is best for the team, they live for opportunities to collaborate and reputed company a difference, and they reputed company us the #1 Top Workplace in the area. Apply tot his job Apply To this Job