Utilization Management Nurse Consultant
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Job Description
Remote utilization management RN reviewing Medicare clinical cases and coverage determinations for CVS Health. Coordinating treatment and improving member outcomes using evidence-based guidelines.
Responsibilities:
- Review clinical cases and make coverage determinations using evidence-based guidelines
- Collaborate with providers and care teams to coordinate appropriate treatment
- Apply clinical judgment to support utilization and benefit management decisions
- Identify opportunities to improve care quality and member outcomes
- Serve as a clinical resource across internal and external stakeholders
- Work a weekday schedule within a 24/7 utilization management operation, including possible holidays and evening hours
Requirements:
- Active, unrestricted RN license in the state of residence
- 3+ years of RN experience, including 1+ year in Med/Surg
- Strong clinical assessment and decision-making skills
- Experience with Microsoft Office (Outlook, Teams, Excel)
- Ability to work Monday–Friday, 9:00 AM–6:00 PM in your time zone; schedules may include holidays and evening hours
- Associate Degree in Nursing
- Direct/hardwired internet connection to a modem/router within 7 feet of the computer
- Minimum internet speed of 25 Mbps download and 3 Mbps upload
- WiFi and satellite internet are not permitted
- Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently residing
- Must provide workspace furniture, such as a desk or standing desk
- Ability to use multiple monitors and navigate multiple applications
- Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
- Experience with Microsoft Office 365 or similar Google Workspace applications
- Ability to log in to secure systems such as VPN and EHR portals
- Ability to manage strong passwords and recognize suspicious emails or links
- Ability to resolve common technical issues independently
- Openness to learning new skills
- BSN preferred
- Utilization Management or Prior Authorization experience, managed care background, familiarity with MedCompass, and ambulatory surgery experience are nice to have
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
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