Remote Medicare Utilization Nurse Consultant

CVS Health; South Dakota; Remote; USD 36,000 - 86,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for Medicare, remote, full-time, with a Monday–Friday 9:00 AM–6:00 PM schedule in your time zone. You will review cases, determine coverage using guidelines, coordinate care with providers, and apply clinical judgment to support utilization decisions.

Ideal candidates hold an active RN license, 3+ years of RN experience including Med/Surg, and proficiency with Microsoft Office.

Qualifications

• Active, unrestricted RN license in the state of residence.
• 3+ years of RN experience, including 1+ year in Med/Surg.
• Strong clinical assessment and decision-making skills.
• Experience with Microsoft Office (Outlook, Teams, Excel).
• Ability to work Monday-Friday, 9:00 AM-6:00 PM in your time zone; Utilization Management is a 24/7 operation and holidays/evenings apply.
• Associate Degree in Nursing.

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

Skills

RN licensure

Clinical assessment

Decision making

Microsoft Office

Schedule flexibility

Remote work capability

Education

Associate Degree in Nursing

Tools

Microsoft Office 365 (Outlook, Teams, Excel)

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for Medicare, remote, full-time, with a Monday–Friday 9:00 AM–6:00 PM schedule in your time zone. You will review cases, determine coverage using guidelines, coordinate care with providers, and apply clinical judgment to support utilization decisions.

Ideal candidates hold an active RN license, 3+ years of RN experience including Med/Surg, and proficiency with Microsoft Office.