Remote Nurse UM Consultant, Spine Care & Coverage Decisions

CVS Health Corporation; United States; Remote; USD 40,000 - 85,000; Full time

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant for the Specialty Spine Team to work remotely. You will review spine-related authorization requests, apply medical necessity guidelines, and collaborate with providers and Medical Directors to ensure timely and accurate coverage determinations.

The role requires an RN with 3–5+ years of clinical nursing experience, an active license, ASN required and BSN preferred.

Qualifications

• Active RN license in state of residence with eligibility for additional state licensure.
• 3–5+ years of clinical nursing experience and strong medical necessity knowledge.
• Experience with evidence-based review and documentation.
• Ability to collaborate with providers and Medical Directors.

Responsibilities

• Review spine-related prior authorization requests and apply evidence-based criteria.
• Assess clinical records, treatment plans, and provider documentation.
• Collaborate with providers, Medical Directors, and health plan teams on care decisions.
• Ensure compliance with regulatory requirements and organizational policies.
• Meet quality, productivity, and turnaround time standards and support process improvements.
• Support timely, accurate coverage determinations in a fast-paced managed care environment.

Skills

Clinical review

Evidence-based practice

Critical thinking

Documentation

Communication

Education

ASN required

BSN preferred

Tools

MCG guidelines

Clinical Policy Bulletins

MedCompass

QNXT

Job description

CVS Health is seeking a Utilization Management Nurse Consultant for the Specialty Spine Team to work remotely. You will review spine-related authorization requests, apply medical necessity guidelines, and collaborate with providers and Medical Directors to ensure timely and accurate coverage determinations.

The role requires an RN with 3–5+ years of clinical nursing experience, an active license, ASN required and BSN preferred.