Remote Utilization Management Nurse Consultant (RN)

CVS Health; Louisiana; Remote; USD 54,000 - 117,000; Full time

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to remotely review authorizations and assess medical necessity across multiple specialties. You will collaborate with care teams to ensure compliant, evidence-based reviews and timely decisions that support quality care and member outcomes.

The role requires 3+ years nursing experience, 2+ years in utilization management or related fields, and active multi-state RN licensure.

Qualifications

• Active, unrestricted multi-state RN license in your state of residence, or ability to obtain multi-state.
• Ability to obtain and maintain additional state licensure as needed.
• 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, critical thinking, and decision-making skills.
• Excellent verbal and written communication skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency with electronic medical records and utilization management systems.

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, care managers, medical directors, and interdisciplinary teams to facilitate quality care.
• Ensure compliance with health plan policies, regulatory requirements, and clinical standards.
• Manage a high-volume caseload while meeting productivity, quality, and turnaround-time expectations.
• Support effective healthcare utilization and positive member outcomes.

Skills

Clinical nursing

Critical thinking

Decision making

Verbal communication

Written communication

Multitasking

EMR proficiency

Education

ASN required

BSN preferred

Tools

InterQual

MCG

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to remotely review authorizations and assess medical necessity across multiple specialties. You will collaborate with care teams to ensure compliant, evidence-based reviews and timely decisions that support quality care and member outcomes.

The role requires 3+ years nursing experience, 2+ years in utilization management or related fields, and active multi-state RN licensure.