Remote RN Utilization Management Consultant

CVS Health Corporation; Austin (TX); Remote; USD 74,722,000 - 160,886,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health Corporation is seeking an experienced Utilization Management Nurse Consultant (RN) to support remote concurrent review. You will review authorization requests, determine medical necessity, and apply clinical criteria to inform denials or approvals while collaborating with care teams.

A multi-state license and 3+ years of UM/CM experience are required. Strong communication, EMR proficiency, and ability to manage a high-volume caseload in a fast-paced environment are essential.

Qualifications

• Active, unrestricted multi-state RN license
• 3+ years of clinical nursing experience
• 2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experience
• Experience reviewing medical records and determining medical necessity
• Experience using InterQual, MCG, or similar clinical decision-support tools
• Strong clinical assessment, critical thinking, and decision-making skills
• Excellent verbal and written communication skills
• Ability to manage multiple priorities in a fast-paced environment
• Proficiency with electronic medical records and utilization management systems

Responsibilities

• Review authorization requests across a broad range of medical specialties
• Evaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements
• Apply InterQual, MCG, or similar clinical criteria to support authorization determinations
• Collaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality care
• Ensure compliance with health plan policies, regulatory requirements, and clinical standards
• Manage a high-volume caseload while meeting productivity, quality, and turnaround-time expectations
• Support effective healthcare utilization and positive member outcomes

Skills

RN License

Multistate License

Clinical Nursing

Utilization Management

Medical Records Review

InterQual/MCG

Communication Skills

EMR Systems

Education

ASN

BSN preferred

Tools

EMR Systems

Job description

CVS Health Corporation is seeking an experienced Utilization Management Nurse Consultant (RN) to support remote concurrent review. You will review authorization requests, determine medical necessity, and apply clinical criteria to inform denials or approvals while collaborating with care teams.

A multi-state license and 3+ years of UM/CM experience are required. Strong communication, EMR proficiency, and ability to manage a high-volume caseload in a fast-paced environment are essential.