Remote Utilization Management Nurse Consultant (RN)

CVS Health; Bastrop (LA); Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Remote work eligibility

Job summary

CVS Health is seeking an experienced Utilization Management RN to join our remote team. You will review authorization requests, assess medical necessity, and apply clinical criteria to determine appropriate care while maintaining compliance with health plan requirements.

The role supports providers, care managers, and interdisciplinary teams to ensure timely, cost-effective services. Qualifications include an active RN license (multi-state preferred), 3+ years of nursing, 2+ years in UM/Prior

Qualifications

• Active, unrestricted RN license in your state of residence (multi-state where applicable).
• 3+ years of clinical nursing experience.
• 2+ years in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review.
• Experience reviewing medical records and determining medical necessity.
• Familiarity with InterQual, MCG, or similar clinical criteria.

Responsibilities

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

Skills

RN license

Utilization management

Clinical nursing experience

Medical records review

InterQual/MCG tools

Multi-state licensure

Prior authorization

Clinical decision-support

Communication skills

Time management

Education

ASN

BSN preferred

Tools

EMR systems

Job description

CVS Health is seeking an experienced Utilization Management RN to join our remote team. You will review authorization requests, assess medical necessity, and apply clinical criteria to determine appropriate care while maintaining compliance with health plan requirements.

The role supports providers, care managers, and interdisciplinary teams to ensure timely, cost-effective services. Qualifications include an active RN license (multi-state preferred), 3+ years of nursing, 2+ years in UM/Prior