Utilization Management Nurse Consultant

CVS Health

1d•$29 - $62•Remote

About The Position

The Utilization Management Nurse Consultant is a remote, full-time Registered Nurse role focused on clinical precertification for Medicare. The position uses clinical expertise in a non-bedside setting to help ensure members receive appropriate care in the right setting. The nurse reviews clinical cases, makes coverage determinations using evidence-based criteria, collaborates with providers and interdisciplinary care teams, and applies clinical judgment to utilization management and prior authorization decisions. The role also identifies opportunities to improve quality, outcomes, and member experience and serves as a clinical resource for internal and external stakeholders. The regular schedule is Monday through Friday, 9:00 AM–5:30 PM in the employee’s local time zone. Because Utilization Management operates 24/7, schedules may include occasional evenings, weekends, and holidays based on business needs. The position is work-from-home, with requirements for a direct wired internet connection, a dedicated private workspace compliant with HIPAA and company security requirements, and work from the confirmed state and city of residence. The company provides a computer, monitor(s), keyboard, and headset; employees provide appropriate workspace furniture. The anticipated schedule is 40 hours per week. The typical pay range is $29.10–$62.32, with the actual offer dependent on experience, education, geography, and other factors. The position is also eligible for a CVS Health bonus, commission, or short-term incentive program. Full-time benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Requirements

Active, unrestricted RN license in the state of residence.
Minimum 3 years of RN experience.
Strong clinical assessment, critical thinking, and decision-making skills.
Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.
Associate Degree in Nursing (ADN).
Ability to work Monday through Friday, 9:00 AM–5:30 PM in the local time zone.
Ability to work occasional evenings, weekends, and holidays based on business needs.
Direct wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
Dedicated, private workspace that complies with HIPAA and company security requirements.
Ability to work from the confirmed state and city of residence.
Commitment to maintaining required internet speeds and remote work standards.
Ability to navigate multiple monitors and applications simultaneously.
Comfort using Teams, Outlook, email, calendars, and virtual meeting platforms.
Experience with Microsoft 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools.
Ability to securely access systems, including VPNs and healthcare applications.
Basic troubleshooting skills, including resolving connectivity and application issues.
Willingness to learn new technology and adapt to evolving business needs.

Nice To Haves

Utilization Management, Prior Authorization, or Care Management experience.
1 year in Medical-Surgical Nursing.
Managed care experience.
Experience using MedCompass or similar utilization management platforms.
Ambulatory surgery or outpatient clinical experience.
Bachelor of Science in Nursing (BSN).

Responsibilities

Review clinical cases and make coverage determinations using evidence-based criteria.
Collaborate with providers and interdisciplinary care teams to support treatment planning.
Apply clinical judgment to utilization management and prior authorization decisions.
Identify opportunities to improve quality, outcomes, and member experience.
Serve as a trusted clinical resource for internal and external stakeholders.