Remote Utilization Management Nurse (Precertification)

CVS Health; Maine; Remote; USD 36,000 - 86,000; Full time

Job summary

CVS Health is seeking a remote Utilization Management Nurse Consultant (Clinical Precertification RN) to evaluate medical necessity for Medicare beneficiaries. You will review cases, determine coverage using guidelines, and coordinate with care teams to ensure appropriate treatment within a fast-paced, 24/7 operating environment.

The role emphasizes strong clinical judgment, collaboration, and the ability to work a weekday schedule from home, with a focus on quality, safety, and patient outcomes.

Qualifications

• Active, unrestricted RN license in the state of residence.
• 3+ years of RN experience, including 1+ year in Med/Surg.
• Strong clinical assessment and decision-making skills.
• Experience with Microsoft Office (Outlook, Teams, Excel).
• Ability to work Monday–Friday, 9:00 AM–6:00 PM in your time zone; Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours.
• Associate Degree in Nursing.

Responsibilities

• Review clinical cases and make coverage determinations using evidence-based guidelines.
• Collaborate with providers and care teams to coordinate appropriate treatment.
• Apply clinical judgment to support utilization and benefit management decisions.
• Identify opportunities to improve care quality and member outcomes.
• Serve as a clinical resource across internal and external stakeholders.

Skills

Clinical assessment

Microsoft Office

Time management

Education

Associate Degree in Nursing

Tools

Microsoft Office 365

Job description

CVS Health is seeking a remote Utilization Management Nurse Consultant (Clinical Precertification RN) to evaluate medical necessity for Medicare beneficiaries. You will review cases, determine coverage using guidelines, and coordinate with care teams to ensure appropriate treatment within a fast-paced, 24/7 operating environment.

The role emphasizes strong clinical judgment, collaboration, and the ability to work a weekday schedule from home, with a focus on quality, safety, and patient outcomes.