Remote Utilization Management Nurse (Medicare)

CVS Health; New Hampshire; Hybrid; USD 40,000 - 86,000; Full time

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant to review cases, determine coverage, and support care planning in a remote setting. The role emphasizes clinical judgment, collaboration with care teams, and improvements to quality and member experience.

Applicant should have an ADN ( BSN preferred) and an unrestricted RN license with 3+ years of RN experience. Monday–Friday, 9:00 AM–5:30 PM in local time; remote work with HIPAA and security compliance.

Qualifications

• Active, unrestricted RN license in the state of residence.
• Minimum 3 years of RN experience.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.
• Associate Degree in Nursing (ADN).

Responsibilities

• Review clinical cases and make coverage determinations using evidence-based criteria.
• Collaborate with providers and interdisciplinary care teams to support treatment planning.
• Apply clinical judgment to utilization management and prior authorization decisions.
• Identify opportunities to improve quality, outcomes, and member experience.
• Serve as a trusted clinical resource for internal and external stakeholders.

Skills

RN license

3+ years RN experience

clinical assessment

critical thinking

MS Office proficiency

Education

Associate Degree in Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

MedCompass

Microsoft 365 (Teams, Outlook, Word, Excel)

VPN access

Job description

CVS Health is seeking a Utilization Management Nurse Consultant to review cases, determine coverage, and support care planning in a remote setting. The role emphasizes clinical judgment, collaboration with care teams, and improvements to quality and member experience.

Applicant should have an ADN ( BSN preferred) and an unrestricted RN license with 3+ years of RN experience. Monday–Friday, 9:00 AM–5:30 PM in local time; remote work with HIPAA and security compliance.