Utilization Management Nurse Consultant
About The Position
CVS Health is hiring a remote, full-time Utilization Management Nurse Consultant to support clinical precertification for Medicare. This non-bedside role uses clinical expertise to help ensure members receive appropriate care in the right setting and at the right time. The position is part of a collaborative Utilization Management team and works Monday through Friday, generally from 9:00 AM to 5:30 PM in the employee’s local time zone. The team operates 24/7, so schedules may occasionally include evenings, weekends, or holidays based on business needs. The role reviews clinical cases and makes coverage decisions using evidence-based criteria, collaborates with providers and interdisciplinary care teams, and applies clinical judgment to utilization management and prior authorization decisions. It also contributes to quality improvement, better outcomes, and member experience, while serving as a clinical resource for internal and external stakeholders. This position is remote and requires a direct wired internet connection meeting minimum speed requirements, a dedicated private workspace compliant with HIPAA and company security requirements, and work from the confirmed state and city of residence. CVS Health provides a computer, monitor(s), keyboard, and headset; employees provide appropriate workspace furniture and are responsible for maintaining internet speeds and remote-work standards. The role requires use of multiple monitors, Microsoft 365 or similar tools, VPNs, and healthcare applications, as well as basic troubleshooting and adaptability to new technology. The position offers a typical pay range of $29.10–$62.32 per hour and is eligible for a CVS Health bonus, commission, or short-term incentive program. Eligible full-time benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 3 years of RN experience, including at least 1 year in Medical-Surgical Nursing.
- Strong clinical assessment, critical thinking, and decision-making skills.
- Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel; experience with Microsoft 365 applications or similar tools.
- Associate Degree in Nursing (ADN).
- Ability to work Monday through Friday, 9:00 AM–5:30 PM in the local time zone; occasional evenings, weekends, or holidays may be scheduled based on business needs.
- Ability to provide a direct wired internet connection with at least 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.
- Ability to securely access systems, including VPNs and healthcare applications.
- Basic troubleshooting skills for connectivity and application issues.
- Willingness to learn new technology and adapt to evolving business needs.
- Employees are responsible for providing appropriate workspace furniture; company-provided equipment includes a computer, monitor(s), keyboard, and headset.
Nice To Haves
- Utilization Management, Prior Authorization, or Care Management experience.
- 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.
- Navigate multiple monitors, applications, healthcare systems, and virtual meeting platforms.
- Maintain required internet speeds and comply with remote-work, HIPAA, and company security requirements.
- Perform basic troubleshooting of connectivity and application issues and learn new technology as needed.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources to support physical, emotional, and financial well-being, subject to eligibility
- Eligible for a CVS Health bonus, commission, or short-term incentive program
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
