Remote Cvs Utilization Management Nurse Jobs in Georgia

Job ID: JP46829

Anticipated Start Date: September 28, 2026

Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.

Primary duties may include, but are not limited to:

• Utilizes nursing judgment and reasoning to analyze members? clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.

• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.

• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members? aggregate symptoms and information.

• Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.

• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.

• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.

• Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.

• Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.

• Serves as a resource to lower-level nurses.

• May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities.

• Educates members about plan benefits and physicians and may assist with case management.

• Collaborates with leadership in enhancing training and orientation materials.

• May complete quality audits and assist management with developing associated corrective action plans.

• May assist leadership and other stakeholders on process improvement initiatives.

• May help to train lower-level clinician staff.
  

Requirements:

• Requires a minimum of associate's degree in nursing.

• Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.

• Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

• Multi-state licensure is required if this individual is providing services in multiple states.
  

Job Type: Contract or Contract to hire

Additional Details:

• InterQual review criteria for inpatient members.

• Anthem Care Management Platform experience a plus.

• Experience of at least 3 years of acute inpatient experience, utilization management experience and discharge planning experience.

• 08:30-05:30 M-F

• Remote, work from home
  

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

About BCForward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.