Remote RN Utilization Management Nurse (Medicare)

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

Job summary

CVS Health is seeking an experienced Registered Nurse for the Medicare Utilisation Management Nurse Consultant role (Remote, Full-Time). You will help ensure members receive the right care at the right time within joint procedures and Medicare pathways.

You’ll review clinical information, apply evidence-based criteria, collaborate with providers and care teams, and identify opportunities to improve care quality while supporting care integration and utilization management.

Qualifications

• Active, unrestricted RN license in the state of residence.
• 3+ years of RN experience.
• 1+ year of Med/Surg experience.
• Proficiency in Microsoft Office (Outlook, Teams, Excel).
• Associate degree in nursing.

Responsibilities

• Review and assess clinical information for Medicare precertification (joint procedures).
• Apply evidence-based criteria and clinical judgement to make coverage determinations.
• Collaborate with providers and care teams to coordinate appropriate treatment plans.
• Identify opportunities to improve care quality and optimise healthcare utilisation.
• Support care integration by connecting members to additional programmes and services.
• Serve as a clinical resource to internal and external partners.

Skills

RN license

RN experience

Med/Surg experience

Microsoft Office

Education

Associate degree in nursing

Tools

Outlook

Teams

Excel

Job description

CVS Health is seeking an experienced Registered Nurse for the Medicare Utilisation Management Nurse Consultant role (Remote, Full-Time). You will help ensure members receive the right care at the right time within joint procedures and Medicare pathways.

You’ll review clinical information, apply evidence-based criteria, collaborate with providers and care teams, and identify opportunities to improve care quality while supporting care integration and utilization management.