Utilization Management Nurse Consultant - Medical Review, Fully Remote

College of Nursing, University of Saskatchewan; Sacramento (CA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading health solutions company is seeking a Remote Registered Nurse to utilize clinical skills in medical review cases. The ideal candidate will have an active RN license and at least 3 years of clinical experience. Responsibilities include applying clinical guidelines, coordinating processes, and training reviewers. This full-time position offers competitive pay ranging from $26.01 to $74.78 per hour along with comprehensive benefits.

Benefits

Affordable medical plan options

401(k) plan

Employee stock purchase plan

Wellness screening programs

Tuition assistance

Qualifications

• Active Registered Nurse (RN) license required.
• 3+ years clinical experience is necessary.
• 1+ year experience in Utilization Review Management or Medical Management is required.

Responsibilities

• Implement, coordinate, monitor, and evaluate medical review cases.
• Apply clinical criteria to make medical determinations.
• Train new nurse reviewers and partners.

Skills

Clinical judgment

Independent decision-making

Proficient use of clinical documentation systems

Education

Associate degree

BSN

Tools

Clinical documentation systems

Phone

Computer

Job description

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

This position will be remote working from home anywhere in the US.

Schedule is Monday - Friday 8am-5pm est.

No travel required.

Non-exempt. Hourly. Pay: Bi-weekly. No shift premium.

Occasional Overtime may be required.

Position Summary

Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.

Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.

Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize

procedures/services or initiate a Medical Director referral as needed.

Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring, feedback,

Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.

Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production,

quality, and client satisfaction.

Must be able to work independently without personal distractions to meet quality and metric expectations.

Required Qualifications

• Registered Nurse (RN) - active license.
• 3+ Years of clinical experience.
• 1+ Year of Utilization Review Management and/or Medical Management experience.
• Must have active and unrestricted RN license in the state you reside.
• 5 years demonstrated to make thorough independent decisions using clinical judgement.
• 5 Years proficient use of equipment experience including phone, computer, etc and clinical documentation systems.
• Required to attend all classes the first 3 weeks of initial training required with 100% participation during 8:00am-5pm Monday-Friday.

Preferred Qualifications

• MCG Milliman, InterQual, CPB or other criteria guideline application experience is preferred.

Education

• Associate degree required
• BSN preferred

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$26.01 - $74.78

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 our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 08/06/2025

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