Remote Utilization Management Nurse Consultant

CVS Health; Arizona; Remote; USD 83,383,000 - 178,573,000; Full time

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant for a 100% work-from-home, full-time position open to MST/PST residents. You will coordinate and document utilization and benefit management activities, ensuring timely, safe, and appropriate care for members.

In this role you will review medical necessity, collaborate with providers, and support cost-effective care while meeting state and federal requirements. Strong clinical judgment and communication are essential.

Qualifications

• Active, unrestricted RN license.
• 2+ years of acute hospital clinical experience (strong preference for medical-surgical, ICU, behavioral health or other specialty area).
• Strong clinical assessment and decision-making abilities.
• Excellent organizational skills with the ability to manage multiple priorities.
• Ability to work independently and communicate effectively via phone.
• Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls.

Responsibilities

• Reviewing services for medical necessity and appropriate benefit use, facilitating efficient discharge planning, and collaborating with providers and facilities to support members with complex needs.
• Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.
• Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations.
• Communicating with providers and external partners to coordinate care and treatment plans.
• Identifying opportunities for referrals to additional programs, services, or care solutions.
• Recognizing opportunities to promote quality care delivery and effective benefit utilization.
• Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.

Skills

RN license

Acute hospital clinical experience

Clinical assessment

Organizational skills

Independent work

Phone communication

Education

ADN

BSN

Tools

Microsoft Office

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant for a 100% work-from-home, full-time position open to MST/PST residents. You will coordinate and document utilization and benefit management activities, ensuring timely, safe, and appropriate care for members.

In this role you will review medical necessity, collaborate with providers, and support cost-effective care while meeting state and federal requirements. Strong clinical judgment and communication are essential.