Remote Utilization Management Nurse Consultant

CVS Health; Arizona; Hybrid; USD 40,000 - 86,000; Full time

Job summary

CVS Health is seeking a Utilization Management Clinical Consultant for a 100% remote role in Arizona. You will handle cases within a Skilled Nursing Facility setting while managing back-end responsibilities, including retrospective reviews and claims analysis after assessment.

The position requires an active Arizona RN license, 3+ years of clinical practice, and a 40-hour work week. The role emphasizes evidence-based care, medical necessity criteria, and collaboration with providers to ensure

Qualifications

• Active, unrestricted Arizona RN license or compact license that includes Arizona.
• 3+ years of clinical practice in hospital, SNF, home health, or ambulatory care.
• Experience with claims review processes and utilization management preferred.
• Knowledge of medical necessity criteria and evidence-based care.
• Excellent clinical judgement and decision making.

Responsibilities

• Coordinate, document and communicate utilization/benefit management activities.
• Apply medical necessity criteria for appropriate service utilization.
• Consult with internal and external stakeholders in utilization management.
• Gather clinical information to render coverage determinations.
• Collaborate with providers to facilitate optimal care.
• Identify patients who may benefit from care management.
• Promote quality and efficiency of healthcare services.

Skills

Clinical coordination

Medical judgement

Documentation

Communication

Team collaboration

Education

RN – Associate degree

BSN preferred

Tools

Electronic Health Records (EHR)

Job description

CVS Health is seeking a Utilization Management Clinical Consultant for a 100% remote role in Arizona. You will handle cases within a Skilled Nursing Facility setting while managing back-end responsibilities, including retrospective reviews and claims analysis after assessment.

The position requires an active Arizona RN license, 3+ years of clinical practice, and a 40-hour work week. The role emphasizes evidence-based care, medical necessity criteria, and collaboration with providers to ensure