Remote Utilization Management RN Consultant

CVS Health; United States; Remote; USD 85,000 - 105,000; Full time

Benefits offered by this job

Remote work option

Equipment provided

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant to remotely review prior authorizations and assess medical necessity across specialties. You will apply evidence-based criteria and collaborate with care teams to ensure quality care while adhering to regulatory standards.

The role demands an active RN license, 3+ years of nursing experience, and 2+ years in utilization management or related areas. This is a remote, multi-state position with focus on timely, compliant decisions.

Qualifications

• Active, unrestricted multi-state RN license in your state of residence.
• 3+ years of clinical nursing experience.
• 2+ years in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review.
• Experience reviewing medical records to determine medical necessity.
• Experience using InterQual, MCG, or similar clinical decision-support tools.
• Strong clinical assessment, critical thinking, and decision-making skills.

Responsibilities

• Review prior authorization requests across a broad range of medical specialties.
• Evaluate medical necessity using clinical records, 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

Multi-state RN license

Critical thinking

Excellent communication

Team collaboration

Education

ASN

BSN preferred

Tools

EMR systems

Clinical decision-support tools (InterQual/MCG)

Job description

CVS Health is seeking a Utilization Management Nurse Consultant to remotely review prior authorizations and assess medical necessity across specialties. You will apply evidence-based criteria and collaborate with care teams to ensure quality care while adhering to regulatory standards.

The role demands an active RN license, 3+ years of nursing experience, and 2+ years in utilization management or related areas. This is a remote, multi-state position with focus on timely, compliant decisions.