Remote Utilization Review RN Consultant

CVS Health Corporation; Louisiana (MO); Hybrid; USD 74,513,000 - 160,864,000; Full time

Benefits offered by this job

Comprehensive benefits

Remote-friendly

Job summary

CVS Health Corporation is seeking an experienced RN for the Utilization Management Nurse Consultant (Remote). This role focuses on concurrent review, prior authorization, and ensuring timely, appropriate, and cost-effective care through evidence-based criteria.

Responsibilities include reviewing authorization requests across specialties, applying InterQual/MCG criteria, collaborating with providers and care teams, and ensuring compliance with policies and HIPAA guidelines while managing a

Qualifications

• Active, unrestricted RN license in your state of residence (multi-state preferred).
• 3+ years of clinical nursing experience.
• 2+ years in Utilization Management, Prior Authorization, Managed Care, or Case Management.
• Experience reviewing medical records and determining medical necessity.

Responsibilities

• Review authorization requests across a broad range of medical specialties.
• Evaluate medical necessity using clinical records, guidelines, and benefit requirements.
• Apply InterQual, MCG, or similar criteria for authorization determinations.
• Collaborate with providers and care teams to facilitate quality care.
• Ensure compliance with health plan policies, regulatory requirements, and clinical standards.
• Manage a high-volume caseload while meeting productivity and quality targets.
• Support appropriate member outcomes and utilization management goals.

Skills

RN license

Clinical nursing

Utilization Management

Clinical decision tools

Communication skills

Multitasking

Education

ASN required

BSN preferred

Tools

InterQual

MCG

Job description

CVS Health Corporation is seeking an experienced RN for the Utilization Management Nurse Consultant (Remote). This role focuses on concurrent review, prior authorization, and ensuring timely, appropriate, and cost-effective care through evidence-based criteria.

Responsibilities include reviewing authorization requests across specialties, applying InterQual/MCG criteria, collaborating with providers and care teams, and ensuring compliance with policies and HIPAA guidelines while managing a