Utilization Management Nurse Consultant

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 - 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.

What You'll Do

• 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, including at least 1 year in Medical-Surgical Nursing
• 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

Note: Utilization Management is a 24/7 operation. Schedules may include occasional evenings, weekends, and holidays based on business needs.

Preferred Qualifications

• Utilization Management, Prior Authorization, or Care Management experience
• Managed care experience
• Experience using MedCompass or similar UM platforms
• Ambulatory surgery or outpatient clinical experience
• Bachelor of Science in Nursing (BSN)

Why Join Us?

• Transition your clinical expertise into a collaborative, non-bedside role
• Make a meaningful impact on healthcare quality and member outcomes
• Work remotely with a supportive and experienced team
• Expand your knowledge of healthcare operations, utilization management, and managed care
• Enjoy opportunities for professional growth and development

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

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

If you're passionate about combining clinical expertise, healthcare quality, and care coordination to improve member outcomes, we'd love to hear from you.

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Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

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

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