The Utilization Management Nurse Consultant utilises 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.

Responsibilities

• Gathers clinical information and applies clinical criteria, guidelines, policies and procedures to render coverage determinations and recommendations along the continuum of care.
• Communicates with providers and other parties to facilitate care and treatment.
• Identifies members for referral opportunities to integrate with other products, services and programmes.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilisation.
• Consults and lends expertise to internal and external constituents in the coordination and administration of the utilisation/benefit management function.
• Works in a typical office environment with productivity and quality expectations.
• Performs close inspection of handwritten and computer-generated documents and PC monitors.
• Sedentary work involving periods of sitting, talking and listening.
• Requires sitting for extended periods, talking on the telephone and typing on the computer.
• Ability to multitask, prioritise and adapt to a fast-paced changing environment.
• Proficiency with computer skills, including navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written.

Requirements

• 2+ years of clinical experience as a Registered Nurse in a hospital setting in adult acute care/critical care setting.
• Active current and unrestricted RN licensure in state of residence.

Preferred Qualifications

• 3+ years of clinical experience in adult med surg or specialty area.
• Managed Care experience preferred, especially Utilisation Management.
• Preference for those residing in CST zone.

Education

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

Work from Home Requirements

• Direct/hardwired internet connection to a modem/router within 7 feet of computer and minimum download speed of 25 Mbps download and 3 Mbps upload.
• Quiet, secure and private designated home virtual work location, free from distractions, tidy and organised, compliant with CVSHealth and HIPAA guidelines.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.).

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognise suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves.

Benefits This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.

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