Utilization Management Nurse Consultant - Medicaid Program
About The Position
At CVS Health, 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 reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary We are seeking a detail‑oriented and dedicated Registered Nurse to support our Medical Management team. In this role, you’ll play an essential part in ensuring members receive timely and accurate communication regarding their healthcare services. You’ll be responsible for composing and auditing approval, extension, and denial letters that meet regulatory, accreditation, and quality standards. Limited phone time. This position supports the overall effectiveness of our medical management programs by promoting clear communication, maintaining precise documentation, and helping ensure members receive high‑quality, appropriate care. If you enjoy a balance of clinical knowledge, writing, and administrative coordination, this role offers an excellent opportunity to apply your skills in a meaningful way.
Requirements
- Registered Nurse (RN) with an active, unrestricted license in the state of residence
- 1+ year of clinical nursing experience
Nice To Haves
- Experience in Utilization Management or Managed Care
- Strong grammar, writing, and editing skills
- Ability to multi‑task and work efficiently in a fast‑paced environment
- Associate or Bachelor’s degree in Nursing
Responsibilities
- Create, review, and audit medical determination letters including approvals, extensions, and denials
- Ensure all documentation meets regulatory, accreditation, and internal quality standards
- Support effective medical management by facilitating clear communication across internal teams and external partners
- Maintain accurate, complete records for compliance and risk‑management requirements
- Contribute to overall quality and effectiveness of healthcare services through attention to detail and process consistency
Benefits
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
