Remote Utilization Review Nurse Consultant

CVS Health; Bastrop (LA); Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Retirement plan

Wellness programs

Job summary

CVS Health is seeking an Utilization Management Nurse Consultant (RN) to review authorization requests across multiple medical specialties, evaluate medical necessity, and apply clinical criteria to support determinations. This remote role collaborates with providers and care teams to ensure timely, cost-effective care.

Active multi-state RN license, 3+ years of nursing, 2+ years in UM/Prior Authorization/Managed Care, experience with InterQual/MCG, strong assessment and communication skills,

Qualifications

• Active, unrestricted multi-state RN license in your state of residence, or ability to obtain and maintain multi-state.
• 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 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

Utilization Management

Medical records review

Communication skills

EMR proficiency

Multi-state licensure

Decision-support tools

Education

ASN

BSN preferred

Tools

InterQual/MCG

EMR systems

Job description

CVS Health is seeking an Utilization Management Nurse Consultant (RN) to review authorization requests across multiple medical specialties, evaluate medical necessity, and apply clinical criteria to support determinations. This remote role collaborates with providers and care teams to ensure timely, cost-effective care.

Active multi-state RN license, 3+ years of nursing, 2+ years in UM/Prior Authorization/Managed Care, experience with InterQual/MCG, strong assessment and communication skills,