Utilization Management Nurse Consultant
About The Position
The RN Utilization Management Nurse Consultant supports Medicare precertification reviews for joint procedures. The nurse reviews clinical information, applies evidence-based criteria and clinical judgment to coverage determinations, collaborates with providers and care teams on appropriate treatment plans, identifies opportunities to improve care quality and healthcare utilization, connects members with additional programs and services, and serves as a clinical resource to internal and external partners. This is a remote, full-time role with a Monday–Friday schedule of 9:00 a.m. to 5:30 p.m. in the employee’s time zone, with occasional evenings and holidays. The position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. The role requires a designated quiet, secure, private home workspace that complies with CVS Health and HIPAA guidelines and supports uninterrupted work. Employees must work within the state and city where they currently live and have confirmed residence. A wired internet connection to a modem or router within seven feet of the computer is required, with at least 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides equipment such as a computer, monitor, keyboard, and headset; employees provide their own workspace furniture. The position involves working with multiple monitors and applications, digital communication and collaboration tools, and secure systems such as VPNs and EHR portals. The employee must follow security practices, troubleshoot common technical issues, and remain open to learning new skills as the workplace evolves.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 3 years of RN experience.
- At least 1 year of Med/Surg experience.
- Proficiency in Microsoft Office, including Outlook, Teams, and Excel.
- Associate degree in nursing.
- Ability to meet the stated home-work 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.
- Ability to work within the state and city of confirmed residence.
- Ability to use multiple monitors and applications and communicate through digital channels and virtual meetings.
- Ability to access secure systems and follow security practices, including locking the computer when unattended, managing strong passwords, and recognizing suspicious emails or links.
- Ability to troubleshoot common technical issues and contact IT for unresolved issues.
- Ability to work a Monday–Friday schedule, with occasional evenings and holidays.
Nice To Haves
- Utilization Management or Prior Authorization experience.
- Managed care and/or Medicare experience.
- MedCompass or similar system experience.
- Ambulatory surgery background.
- Bachelor of Science in Nursing (BSN).
Responsibilities
- Review and assess clinical information for Medicare precertification of 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.
- Connect members to additional programs and services to support care integration.
- Serve as a clinical resource to internal and external partners.
Benefits
- Medical coverage.
- Dental coverage.
- Vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Other resources, based on eligibility.
- Eligible for a CVS Health bonus, commission, or short-term incentive program.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
