Utilization Management Nurse Consultant

CVS Health•Washington, NV

8d•$29 - $62•Remote

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 nursing expertise to help ensure members receive appropriate care in the right setting and at the right time. The consultant reviews clinical cases, makes coverage determinations using evidence-based criteria, collaborates with providers and interdisciplinary care teams, and applies clinical judgment to utilization management and prior authorization decisions. The role also identifies opportunities to improve quality, outcomes, and member experience, and serves as a clinical resource for internal and external stakeholders. The standard schedule is Monday through Friday, 9:00 AM–5:30 PM in the employee’s local time zone. Because Utilization Management operates 24/7, occasional evening, weekend, or holiday work may be required based on business needs. The role is remote, with work performed from the employee’s confirmed state and city of residence. Remote-work conditions include a direct wired internet connection meeting minimum speed requirements, a dedicated private workspace compliant with HIPAA and company security requirements, and ongoing compliance with remote-work standards. The company provides a computer, monitor(s), keyboard, and headset; employees provide appropriate workspace furniture. The position is scheduled for 40 hours per week. The listed pay range is $29.10–$62.32, and the position is eligible for a CVS Health bonus, commission, or short-term incentive program. Full-time benefits may 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.
Minimum 3 years of RN experience.
Strong clinical assessment, critical-thinking, and decision-making skills.
Associate Degree in Nursing (ADN).
Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.
Ability to work Monday through Friday, 9:00 AM–5:30 PM in the local time zone.
Ability to work from the confirmed state and city of residence.
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 maintain required internet speeds and meet remote-work standards.
Ability to navigate multiple monitors and applications simultaneously.
Comfort using Teams, Outlook, email, calendars, and virtual meeting platforms.
Ability to securely access systems, including VPNs and healthcare applications.
Basic troubleshooting skills, including resolving connectivity and application issues.
Willingness to learn new technology and adapt to evolving business needs.
Ability to work occasional evenings, weekends, and holidays based on business needs.

Nice To Haves

Utilization Management, Prior Authorization, or Care Management experience.
One year of Medical-Surgical Nursing experience.
Managed care experience.
Experience using MedCompass or similar utilization management platforms.
Ambulatory surgery or outpatient clinical experience.
Bachelor of Science in Nursing (BSN).
Experience with Microsoft 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools.

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.
Maintain required internet speeds and comply with remote-work standards.
Work occasional evenings, weekends, or holidays when required by business needs.