Utilization Management Nurse Consultant

CVS Health

1d•$26 - $62•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. RN Utilization Management Nurse Consultant (Medicare – Joint Procedures) Remote | Full-Time | Monday–Friday (9:00 am to 6:00 pm in your time zone, with occasional evenings/holidays) Are you an experienced Registered Nurse looking to make an impact beyond the bedside? Join a collaborative Utilization Management team where your clinical expertise helps ensure members receive the right care at the right time.

Requirements

Active, unrestricted RN license in the state of residence
3+ years of RN experience
1+ year of Med/Surg experience
Proficiency in Microsoft Office (Outlook, Teams, Excel)
Associates degree in nursing

Nice To Haves

Utilization Management or Prior Authorization experience
Managed care and/or Medicare experience
MedCompass or similar system experience
Ambulatory surgery background

Responsibilities

Review and assess clinical information for Medicare precertification (joint procedures)
Apply evidence-based criteria and clinical judgment to make coverage determinations
Collaborate with providers and care teams to coordinate appropriate treatment plans
Identify opportunities to improve care quality and optimize healthcare utilization
Support care integration by connecting members to additional programs and services
Serve as a clinical resource to internal and external partners