Remote Utilization Nurse Consultant (Medical Review)

CVS Health; Kansas City (MO); Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Bonus program

Comprehensive benefits package

Job summary

American Health Holding, Inc. (an division of CVS Health) is seeking a Utilization Management Nurse Consultant specializing in Medical Review. This fully remote role emphasizes precise clinical review, collaboration with providers, and compassionate patient care in a fast-paced desk-based setting.

You will leverage your RN expertise to evaluate medical necessity, apply criteria, and provide timely determinations while supporting cross-training and process improvements for client satisfaction.

Qualifications

• Active, unrestricted RN license in your state with multistate/compact licensure.
• Minimum 3 years of clinical experience.
• 5 years demonstrated ability to make independent decisions using clinical judgement.
• 5 years proficiency with equipment and clinical documentation systems.
• 1+ year of Utilization Review Management/Medical Management experience.
• Commitment to attend a mandatory 3-week training (Mon–Fri, 8:30am–5:00pm EST) with 100% participation.

Responsibilities

• Utilizes clinical experience to implement, coordinate, monitor and evaluate medical review cases.
• Applies clinical criteria and policy specifics to render medical determinations.
• Uses evidence-based criteria and guidelines to authorize procedures or refer to Medical Director as needed.
• Mentors and trains new nurse reviewers and vendors.
• Cross-trains to review multiple case types to meet client needs.
• Suggests improvements in processes and technology to enhance quality and client satisfaction.
• Works independently.

Skills

RN license

Clinical experience

Independent clinical decisions

Medical documentation systems

Utilization Review experience

Training commitment

Education

Associate's degree in nursing

BSN preferred

Job description

American Health Holding, Inc. (an division of CVS Health) is seeking a Utilization Management Nurse Consultant specializing in Medical Review. This fully remote role emphasizes precise clinical review, collaboration with providers, and compassionate patient care in a fast-paced desk-based setting.

You will leverage your RN expertise to evaluate medical necessity, apply criteria, and provide timely determinations while supporting cross-training and process improvements for client satisfaction.