Remote Utilization Management Nurse Consultant

NurseRemotely; United States; Remote; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking a remote Utilization Management Nurse Consultant (RN) to review authorization requests across medical specialties and determine medical necessity using evidence-based guidelines. The role emphasizes collaboration with providers and care teams to ensure appropriate care and compliance with policies.

Qualifications include an active multi-state RN license, 3+ years nursing and 2+ years UM/CR experience, and proficiency with EMR and decision-support tools.

Qualifications

• Active, unrestricted RN license in your state or ability to obtain multi-state licensure.
• 3+ years of clinical nursing experience.
• 2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experience.

Responsibilities

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

Skills

RN license

Multi-state licensure

UM/Prior Authorization

InterQual/MCG criteria

Clinical assessment

EMR proficiency

Communication skills

Education

ASN required

BSN preferred

Job description

CVS Health is seeking a remote Utilization Management Nurse Consultant (RN) to review authorization requests across medical specialties and determine medical necessity using evidence-based guidelines. The role emphasizes collaboration with providers and care teams to ensure appropriate care and compliance with policies.

Qualifications include an active multi-state RN license, 3+ years nursing and 2+ years UM/CR experience, and proficiency with EMR and decision-support tools.