Utilization Management Nurse Consultant

CVS Health • Indianapolis, NV

1d • $26 - $56 • Remote

About The Position

The Utilization Management Nurse Consultant is a remote, full-time clinical precertification RN position on the Medicare Complex Spine Team. The role uses nursing expertise to review clinical cases and make coverage determinations based on evidence-based guidelines. The nurse collaborates with providers and care teams to coordinate appropriate treatment, applies clinical judgment to utilization and benefit management decisions, identifies opportunities to improve care quality and member outcomes, and serves as a clinical resource for internal and external stakeholders.

The position is a work-from-home role requiring a quiet, secure, private designated workspace and a direct hardwired internet connection meeting specified speed requirements. Colleagues must work from the state and city where they have confirmed they live. CVS Health provides computer equipment and related peripherals, while the colleague provides workspace furniture. The work involves using multiple applications and monitors, digital communication and collaboration tools, secure systems, and basic troubleshooting. The stated schedule is Monday through Friday, 9:00 AM to 5:30 PM in the employee’s time zone; however, schedules may include holidays and evening hours because Utilization Management operates 24/7.

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–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 minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted.
• Ability to maintain a quiet, secure, private, organized home workspace that complies with CVS Health and HIPAA guidelines and allows uninterrupted work.
• Work-from-home colleagues must work within the state and city where they have confirmed they currently live.
• Provide workspace furniture, such as a desk or standing desk, and be able to work at a desk for extended periods.
• Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
• Ability to use Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to log in to secure systems such as VPNs and EHR portals, follow computer and password security practices, and recognize suspicious emails or links.
• Ability to troubleshoot common technical issues, including restarting frozen applications and resolving internet connection issues.
• Openness 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.
• Bachelor of Science in Nursing (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.
• Use multiple monitors and applications to streamline tasks and improve efficiency.
• Communicate through email, calendar invites, Teams messaging, and virtual meetings.
• Access secure systems and follow security practices, including locking unattended computers 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 in addition to base pay.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree