UM Nurse Consultant | Specialty UM - Spine

CVS Health Corporation; Ohio; Hybride; USD 40 000 - 85 000; Plein temps

Avantages offerts par ce poste

Medical, dental, and vision coverage

Paid time off

Résumé du poste

CVS Health Corporation invites an experienced Utilization Management Nurse Consultant to join the Spine Team in a remote, full-time capacity. You will review spine-related prior authorizations, apply evidence-based criteria, and collaborate with providers and Medical Directors to support appropriate care decisions.

The role requires 3–5+ years of clinical nursing, an active RN license, and strong documentation and communication skills. Minimum ASN; BSN preferred.

Qualifications

• Active, unrestricted RN license in state of residence.
• 3–5+ years of clinical nursing experience.
• Knowledge of medical necessity review and evidence-based practice.
• Strong communication and thorough documentation skills.
• Willingness to obtain additional state licensure as needed.

Responsabilités

• Review prior authorization requests for spine procedures and services.
• Apply criteria including MCG guidelines and clinical policies.
• Assess clinical records and treatment plans.
• Collaborate with providers, Medical Directors, and plan teams.
• Ensure regulatory and organizational compliance; meet quality targets.

Connaissances

RN license

Clinical nursing

Critical thinking

Communication

Documentation

Formation

ASN required

BSN preferred

Outils

Microsoft Office 365

EHR portal

Description du poste

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Utilization Management Nurse Consultant, Specialty Spine Team (Remote)

Schedule

Monday-Friday, 8:00 AM-5:00 PM EST/CST, with rotating weekend and holiday coverage

Are you an experienced RN with a passion for clinical review, evidence-based decision-making, and specialty spine care? Join our Utilization Management (UM) Spine Team and play a critical role in ensuring members receive high-quality, medically necessary care.

What You'll Do

• Review prior authorization requests for spine-related procedures and services
• Apply evidence-based criteria, including MCG guidelines and clinical policies
• Assess clinical records, treatment plans, and provider documentation
• Partner with providers, Medical Directors, and health plan teams to support appropriate care decisions
• Ensure compliance with regulatory and organizational requirements
• Meet quality, productivity, and turnaround time standards while contributing to process improvements

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in state of residence
• Willingness to obtain additional state licensure as needed
• 3-5+ years of clinical nursing experience
• Strong knowledge of medical necessity review and evidence-based practice
• Excellent critical thinking, communication, and documentation skills

Preferred Qualifications

• Experience in orthopedics, spine surgery, neurosurgery, pain management, rehabilitation, or utilization management
• Managed care, health plan, or payer experience
• Knowledge of Medicaid programs and authorization requirements
• Experience with MCG, Clinical Policy Bulletins, MedCompass, QNXT, or similar UM platforms
• Eastern or Central Time Zone preferred
• BSN preferred

Education

• Associate Degree in Nursing (ASN) required
• Bachelor of Science in Nursing (BSN) preferred

Join a team dedicated to clinical excellence, consistency, and quality outcomes while making a meaningful impact on members' care journeys.

Work from Home Requirements

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/17/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.