Utilization Management Nurse Consultant - Fully Remote

The Muse - Boise, ID

Job Title: Utilization Management Nurse Consultant - Fully Remote

Position: Clinical Utilization Management Nurse

Job Type: Full Time

Pay: $26.01 - $74.78

Shift: Monday-Friday: 11:30am-8:00pm EST; 8:30am-5:00pm PST; or 9:30-6:00pm MST

Work Type: Remote

Location

Address:

City: Boise

State: ID

ZIP Code:

Job Responsibilities

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Applies 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 appropriate clinical criteria/guideline, policy, 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.
Promotes 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.
Functions in a clinical telephone queue working with providers to secure additional information for prior authorization review.

Required Skills

Core Skills

1 year experience in Utilization Management, concurrent review or prior authorization
5 years clinical experience
Demonstrated ability to make thorough independent decisions using clinical judgment
Proficient use of equipment including phone, computer and clinical documentation systems

Preferred Skills

1+ years Managed Care (MCO) experience
1+ years experience in a high volume clinical call center environment
Remote work experience

Requirements

Experience: 1 year in UM, 5 years clinical experience

Education: Associate's nursing degree (RN) minimum required; Bachelor's degree preferred

License & Certification:

Unrestricted RN license in state of residence with multi-state/compact privileges

Schedule:

First 3 weeks require 100% participation during 8:30am-5pm Monday-Friday

COVID-19 Requirements: Not Specified

Benefits

Affordable medical plan options
401(k) plan with company matching contributions
Employee stock purchase plan
Wellness screenings, tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Supplemental Pay

Eligible for bonuses, commissions, or short-term incentive program

Special Notes

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
CVS Health fosters a workplace where every colleague feels valued and that they belong.

Facility Details

Name: The Muse

Description: Medical management company that is a division within Aetna/CVS Health, URAC accredited in Case Management, Disease Management and Utilization Management.

Specialties: