Remote Utilization Management Nurse Consultant (Concurrent Review)

4004 Aetna Medicaid Administrators; Louisiana (MO); Hybrid; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is hiring for an Utilization Management Nurse Consultant (RN) for remote work. The role focuses on concurrent review and ensuring timely, cost-effective care through evidence-based decision-making.

Candidates need active RN licensure, multi-state capability, and 3+ years nursing experience, including 2+ years in utilization management. The position emphasizes collaboration with providers and care teams, adherence to policies, and handling a high-volume caseload while maintaining

Qualifications

• Active, unrestricted multi-state RN license in your state of residence 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
• Experience reviewing medical records and determining medical necessity
• Experience using InterQual, MCG, or similar clinical decision-support tools
• Strong clinical assessment and communication skills

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 and interdisciplinary teams to facilitate quality care
• Ensure compliance with health plan policies and regulatory requirements
• Manage a high-volume caseload while meeting productivity and quality targets
• Support effective healthcare utilization and positive member outcomes

Skills

RN license

Utilization management

Medical records review

InterQual/MCG criteria

Communication skills

Education

ASN required

BSN preferred

Tools

InterQual

MCG

Job description

CVS Health is hiring for an Utilization Management Nurse Consultant (RN) for remote work. The role focuses on concurrent review and ensuring timely, cost-effective care through evidence-based decision-making.

Candidates need active RN licensure, multi-state capability, and 3+ years nursing experience, including 2+ years in utilization management. The position emphasizes collaboration with providers and care teams, adherence to policies, and handling a high-volume caseload while maintaining