Utilization Management Nurse Consultant

CVS Health•Washington, NV

3d•$26 - $62•Remote

About The Position

CVS Health is hiring a remote, full-time Utilization Management Nurse Consultant Clinical Precertification RN (Medicare). In this non-bedside role, the nurse uses clinical expertise to review cases, make coverage determinations, and support appropriate care through evidence-based guidelines, clinical judgment, and collaboration with providers and care teams. The position focuses on utilization and benefit management, care quality, and member outcomes, while serving as a clinical resource for internal and external stakeholders. The role is scheduled Monday through Friday, 9:00 AM–6:00 PM in the employee’s time zone. Utilization Management operates 24/7, and schedules may include holidays and evening hours. The position is work-from-home within the state and city where the employee resides. Home-work requirements include a direct wired internet connection meeting specified speed minimums, a quiet and secure designated workspace compliant with CVS Health and HIPAA guidelines, and the ability to work uninterrupted. CVS Health provides computer equipment; the employee supplies workspace furniture. The role requires comfort navigating multiple applications and monitors, communicating through digital channels and virtual meetings, using collaboration and productivity tools, accessing secure systems, maintaining basic security practices, and troubleshooting common technical issues. The position is full-time, with 40 anticipated weekly hours. The pay range is $26.01–$62.32 per hour, with eligibility for a CVS Health bonus, commission, or short-term incentive program. 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 Med/Surg.
Strong clinical assessment and decision-making skills.
Experience with Microsoft Office, including Outlook, Teams, and Excel.
Ability to work Monday through Friday, 9:00 AM–6:00 PM in the employee’s time zone; schedules may include holidays and evening hours.
Associate Degree in Nursing.
Meet work-from-home requirements, including a direct wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
Maintain a quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines.
Work within the state and city where the employee has confirmed they currently live.
Provide workspace furniture and commit to meeting the work-from-home requirements.
Be comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
Communicate using digital channels such as email, calendar invites, Teams messaging, and virtual meetings.
Use Microsoft Office 365 applications or similar tools such as Google Workspace.
Access secure systems, lock the computer when unattended, manage strong passwords, and recognize suspicious emails or links.
Resolve common technical issues independently and contact IT for unresolved issues.
Be open to learning new skills as the workplace environment evolves.

Nice To Haves

Utilization Management or Prior Authorization experience.
Managed care background.
Familiarity with MedCompass.
Ambulatory surgery experience.
BSN preferred.

Responsibilities

Review clinical cases and make coverage determinations using evidence-based guidelines.
Collaborate with providers and care teams to coordinate appropriate treatment.
Apply clinical judgment to support utilization and benefit management decisions.
Identify opportunities to improve care quality and member outcomes.
Serve as a clinical resource across internal and external stakeholders.