# Utilization Management Nurse Consultant Clinical Precertification RN (Medicare)

**Company**: CVS Health
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $29.10 - $62.32
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/PA---Work-from-home/Utilization-Management-Nurse-Consultant_R1095942?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/job/utilization-management-nurse-consultant-clinical-575dcfa9-6a3/

## Description

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

The Utilization Management Nurse Consultant (Clinical Precertification RN - Medicare) is responsible for conducting utilization management and prior authorization reviews to ensure members receive medically appropriate, cost-effective care based on established clinical guidelines and benefit plans.

**Responsibilities** In this fully remote role, you will apply clinical expertise and critical thinking skills to review cases, make coverage determinations, collaborate with providers and interdisciplinary teams, and support high-quality healthcare outcomes.

**Requirements**

- Active, unrestricted Registered Nurse (RN) license in the state of residence.

- Associate Degree in Nursing (ADN) or higher.

- Minimum of 3 years of clinical RN experience.

- At least 1 year of Medical-Surgical (Med/Surg) nursing experience.

- Strong clinical assessment, analytical, and decision-making skills.

- Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.

- Ability to work a full-time schedule Monday through Friday from 9:00 AM to 6:00 PM EST.

- Flexibility to support a 24/7 Utilization Management operation, including occasional holidays, evening hours, and schedule adjustments as business needs require.

**Preferred Qualifications**

- 1 year + Knowledge of Medicare guidelines, medical necessity criteria, and evidence-based review processes.

- Previous Utilization Management (UM), Prior Authorization, or Concurrent Review experience.

- Managed care, health plan, or payer-side clinical experience.

- Experience using MedCompass or similar utilization management platforms.

- Ambulatory surgery, procedural, or perioperative nursing experience.

- Bachelor of Science in Nursing (BSN).

- Experience collaborating with physicians, providers, and interdisciplinary healthcare teams in care coordination activities.

**Benefits** 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.

**Pay Range** The typical pay range for this role is: $29.10 - $62.32

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## Skills

### Required
- Registered Nurse (RN)
- Microsoft Office
- Medical-Surgical nursing
- Clinical assessment
- Analytical skills

### Nice to have
- Medicare guidelines
- Utilization Management
- Prior Authorization
- MedCompass
- Bachelor of Science in Nursing

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Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/PA---Work-from-home/Utilization-Management-Nurse-Consultant_R1095942?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)