Utilization Management Nurse Consultant

CVS Health

1d•$26 - $69•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Medicare Precertification Utilization Management Nurse Consultant (Remote) Schedule: Monday–Friday, 9:00 AM – 6:00 PM (local time); includes occasional evenings, holidays, and participation in a 24/7 operation. About the Role We’re seeking a Registered Nurse (RN) with strong clinical judgment to join our Utilization Management team. In this role, you’ll help ensure members receive appropriate, high-quality, and cost-effective care by reviewing clinical information, making coverage determinations, and collaborating with providers and care teams.

Requirements

Active, unrestricted RN license in state of residence
3+ years of RN experience
1+ year of Med/Surg experience
Proficiency with Microsoft Office (Outlook, Teams, Excel)
Associate’s degree in nursing (BSN preferred)

Nice To Haves

Utilization Management or Prior Authorization experience
Managed care and/or Medicare experience
Experience with MedCompass
Ambulatory surgery experience

Responsibilities

Review and assess clinical information using established guidelines and criteria
Make coverage determinations across the continuum of care
Collaborate with providers and internal partners to coordinate care
Identify opportunities to improve care quality and utilization outcomes
Refer members to programs and services that support better health outcomes
Serve as a clinical resource for internal and external stakeholders