Utilization Management Nurse Consultant
About The Position
The Utilization Management Nurse Consultant (Clinical Precertification RN - Medicare) conducts utilization management and prior authorization reviews to ensure members receive medically appropriate, cost-effective care based on established clinical guidelines and benefit plans. This fully remote, non-bedside role applies clinical expertise and critical thinking to review cases, make coverage determinations, collaborate with providers and interdisciplinary teams, and support high-quality healthcare outcomes. The role requires a designated, quiet and secure home workspace that complies with CVS Health and HIPAA guidelines, a direct wired internet connection meeting specified speed requirements, and the ability to work from the state and city where the employee lives. CVS Health provides computer equipment and related accessories; employees provide their own desk or standing desk. The position requires navigating multiple monitors and applications, using digital communication and collaboration tools, accessing secure systems, following security practices, and troubleshooting common technical issues.
Requirements
- Hold an active, unrestricted Registered Nurse (RN) license in the state of residence.
- Have an Associate Degree in Nursing (ADN) or higher.
- Have at least 3 years of clinical RN experience.
- Have at least 1 year of Medical-Surgical (Med/Surg) nursing experience.
- Demonstrate strong clinical assessment, analytical, and decision-making skills.
- Be proficient with Microsoft Office applications, including Outlook, Teams, and Excel.
- Be able to work full time Monday through Friday from 9:00 AM to 6:00 PM EST, with flexibility to support a 24/7 operation, including occasional holidays, evening hours, and schedule adjustments.
- Meet work-from-home requirements, including a direct wired internet connection with at least 25 Mbps download and 3 Mbps upload, a quiet and secure private workspace, and compliance with CVS Health and HIPAA guidelines.
- Be comfortable using multiple monitors and applications, digital communication tools, secure systems, and common technical troubleshooting procedures.
Nice To Haves
- At least 1 year of knowledge of Medicare guidelines, medical necessity criteria, and evidence-based review processes.
- Previous Utilization Management (UM), Prior Authorization, or Concurrent Review experience.
- Managed care, health plan, or payer-side clinical experience.
- Experience using MedCompass or a similar utilization management platform.
- Ambulatory surgery, procedural, or perioperative nursing experience.
- Bachelor of Science in Nursing (BSN).
- Experience collaborating with physicians, providers, and interdisciplinary healthcare teams in care coordination activities.
Responsibilities
- Conduct utilization management and prior authorization reviews.
- Review cases and make coverage determinations based on clinical guidelines and benefit plans.
- Collaborate with providers and interdisciplinary teams.
- Support care coordination and high-quality healthcare outcomes.
- Work a Monday-through-Friday schedule and provide flexibility to support a 24/7 Utilization Management operation, including occasional holidays, evening hours, and schedule adjustments as business needs require.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
