Remote Utilization Management Nurse Consultant (RN)

CVS Health Corporation; United States; 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

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to evaluate requests for authorization across medical specialties and ensure timely, cost-effective care. The role emphasizes evidence-based review and collaboration with care teams in a remote setting.

The position requires active multi-state RN licensure, 3+ years of clinical nursing, and 2+ years of Utilization Management experience, with BSN preferred and ASN required.

Qualifications

• Active, unrestricted multi-state RN license in state of residence or ability to obtain and maintain multi-state licensure
• 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 criteria to support determinations
• Collaborate with providers, care managers, medical directors, and interdisciplinary teams
• 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

RN nursing license

Utilization Management

Medical records review

InterQual/MCG

EMR proficiency

Multi-state licensure

Communication skills

Time management

Critical thinking

Decision-making

Education

ASN required

BSN preferred

Tools

InterQual/MCG

EMR systems

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to evaluate requests for authorization across medical specialties and ensure timely, cost-effective care. The role emphasizes evidence-based review and collaboration with care teams in a remote setting.

The position requires active multi-state RN licensure, 3+ years of clinical nursing, and 2+ years of Utilization Management experience, with BSN preferred and ASN required.