Description
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 colleagues who care deeply, innovate with purpose, hold themselves accountable, and prioritize safety and quality in everything they do.
Utilization Management Nurse Consultant - Clinical Precertification RN (Medicare)
Remote | Full-Time | Monday-Friday
Are you a Registered Nurse looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care, at the right time, in the right setting.
Responsibilities
- Review clinical cases and make coverage determinations using evidence-based criteria
- Collaborate with providers and interdisciplinary care teams to support treatment planning
- Apply clinical judgment to utilization management and prior authorization decisions
- Identify opportunities to improve quality, outcomes, and member experience
- Serve as a trusted clinical resource for internal and external stakeholders
Required Qualifications
- Active, unrestricted RN license in the state of residence
- Minimum 3 years of RN experience
- Strong clinical assessment, critical thinking, and decision-making skills
- Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel
- Associate Degree in Nursing (ADN)
- Ability to work Monday-Friday, 9:00 AM-5:30 PM in your local time zone
- Utilization Management is a 24/7 operation. Schedules may include occasional evenings, weekends, and holidays based on business needs.
- Work-from-Home Requirements:
- Direct wired internet connection (minimum 25 Mbps download / 3 Mbps upload); Wi-Fi and satellite internet are not permitted
- Dedicated, private workspace that complies with HIPAA and company security requirements
- Ability to work from your confirmed state and city of residence
- Company-provided equipment includes computer, monitor(s), keyboard, and headset
- Employees are responsible for providing appropriate workspace furniture
- Commitment to maintaining required internet speeds and remote work standards
Preferred Qualifications
- Utilization Management, Prior Authorization, or Care Management experience
- 1 year in Medical-Surgical Nursing
- Managed care experience
- Experience using MedCompass or similar UM platforms
- Ambulatory surgery or outpatient clinical experience
- Bachelor of Science in Nursing (BSN)
Technical Requirements
- Ability to navigate multiple monitors and applications simultaneously
- Comfortable using Teams, Outlook, email, calendars, and virtual meeting platforms
- Experience with Microsoft 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools
- Ability to securely access systems, including VPNs and healthcare applications
- Basic troubleshooting skills, including resolving connectivity and application issues
- Willingness to learn new technology and adapt to evolving business needs
Pay Range
The typical pay range for this role is: $29.10 - $62.32
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.