Utilization Management Nurse Consultant
About The Position
CVS Health is seeking a remote, full-time Utilization Management Nurse Consultant Clinical Precertification RN (Medicare). The role uses nursing expertise beyond the bedside to help ensure members receive appropriate care at the right time. The nurse reviews clinical cases, makes coverage determinations using evidence-based guidelines, collaborates with providers and care teams, applies clinical judgment to utilization and benefit management decisions, and identifies opportunities to improve care quality and member outcomes. The position also serves as a clinical resource for internal and external stakeholders. The stated schedule is Monday through Friday, 9:00 AM–5:30 PM in the employee’s time zone. Utilization Management operates 24/7, and schedules will include holidays and evening hours. The position is remote, with work required from the state and city where the employee lives. Home-work requirements include a quiet, secure, private workspace and a direct wired internet connection meeting the specified speed requirements. CVS Health provides computer equipment and related peripherals; the employee supplies workspace furniture. The role requires navigating multiple applications and monitors, using communication and collaboration tools, accessing secure systems, following security practices, and handling basic technical troubleshooting. The anticipated schedule is 40 hours per week. The stated hourly pay range is $29.10–$62.32. The position is eligible for a CVS Health bonus, commission, or short-term incentive program, in addition to the base pay range. 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.
- 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–Friday, 9:00 AM–5:30 PM in the employee’s time zone; schedules may include holidays and evening hours.
- Associate Degree in Nursing.
- Ability to obtain and maintain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with at least 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
- A quiet, secure, private designated home workspace that is free from distractions, organized, compliant with CVS Health and HIPAA guidelines, and allows uninterrupted work.
- Work from within the state and city where the employee currently lives.
- Provide personal workspace furniture, such as a desk or standing desk, and be able to work at a desk for extended periods.
- Ability to set up and use multiple monitors and navigate multiple applications simultaneously.
- Ability to use digital communication tools, secure systems such as VPNs and EHR portals, and Microsoft Office 365 or similar applications.
- Ability to recognize suspicious emails or links and perform common technical troubleshooting.
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.
- Navigate multiple monitors and applications and communicate through digital channels.
- Access secure systems and follow security practices, including locking unattended devices and managing strong passwords.
- Resolve common technical issues independently and contact IT for issues that cannot be resolved.
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.
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
