Remote Medicare Utilization RN Consultant

CVS Health; Rhode Island; Remote; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant to support a 24/7 operation. The role requires RN licensure, 3+ years of RN experience, and 1+ year in Med/Surg, with utilization management responsibilities across clinical criteria and coordination of care.

The position involves collaborating with providers, reviewing information, and promoting efficient, high-quality care. Some home-work requirements and flexible scheduling apply.

Qualifications

• Associates degree required.
• BSN preferred.
• Active RN licensure in state of residence required.
• Minimum 1 year Med/Surg experience.
• Experience with Microsoft Office applications (Outlook, Teams, Excel).

Responsibilities

• Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Apply clinical criteria/guidelines to render coverage determinations/recommendations.
• Communicate with providers and other parties to facilitate care/treatment.
• Identify members for referral opportunities to integrate with other products/services/programs.
• Promote quality effectiveness of Healthcare Services and benefit utilization.
• Lend clinical expertise to coordination and administration of utilization/benefit management.

Skills

RN Experience

Active RN Licensure

Med/Surg Experience

MS Office

Education

Associates degree

BSN preferred

Tools

MedCompass

Microsoft Office 365

Job description

CVS Health is seeking a Medicare Precertification Utilization Management Nurse Consultant to support a 24/7 operation. The role requires RN licensure, 3+ years of RN experience, and 1+ year in Med/Surg, with utilization management responsibilities across clinical criteria and coordination of care.

The position involves collaborating with providers, reviewing information, and promoting efficient, high-quality care. Some home-work requirements and flexible scheduling apply.