Remote RN: Utilization Management Specialist

CVS Health; Louisiana; Remote; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for a remote role focusing on concurrent review. You will review authorization requests, assess medical necessity, and ensure timely, cost-effective care aligned with plan requirements.

Required RN license, multi-state eligibility, 3+ years nursing and 2+ years UM/POA experience. Strong communication, EMR proficiency, and ability to work independently from home are essential.

Qualifications

• Active, unrestricted RN license in state of residence or ability to obtain multi-state license
• Ability to obtain and maintain additional state licensure as needed
• 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

Multi-state license

Clinical nursing experience

Utilization Management

Medical records review

InterQual/MCG

Clinical assessment

Communication skills

Multitasking

EMR proficiency

Education

ASN

BSN

Tools

InterQual/MCG

EMR systems

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for a remote role focusing on concurrent review. You will review authorization requests, assess medical necessity, and ensure timely, cost-effective care aligned with plan requirements.

Required RN license, multi-state eligibility, 3+ years nursing and 2+ years UM/POA experience. Strong communication, EMR proficiency, and ability to work independently from home are essential.