Remote Utilization Management Nurse Consultant (RN)

CVS Health; Georgia; Hybrid; USD 36,000 - 77,000; Full time

Benefits offered by this job

Remote work

Comprehensive benefits

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant for a 100% work-from-home role in the EST time zone. The position supports utilization management and benefit coordination, requiring an active RN license and hospital experience.

Responsibilities include reviewing medical necessity, coordinating with providers, and ensuring timely care while meeting state and federal requirements. Strong documentation and communication skills are essential.

Qualifications

• Active, unrestricted RN license.
• 2+ years of acute hospital clinical experience.
• 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

Phone communication

Computer proficiency

Education

Associate Degree in Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Microsoft Office

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant for a 100% work-from-home role in the EST time zone. The position supports utilization management and benefit coordination, requiring an active RN license and hospital experience.

Responsibilities include reviewing medical necessity, coordinating with providers, and ensuring timely care while meeting state and federal requirements. Strong documentation and communication skills are essential.