Utilization Management Nurse Consultant, CVS Health

CVS Health

Location:
United States, Remote

Category:
Nursing

Contract Type:
Employment contract

Salary:

26.01 - 74.78 USD / Hour

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Job Description:

100% remote position from anywhere in the U.S. Work in clinical telephone queue working with providers to secure additional information for prior authorization review. Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program for CVS Health/Aetna.

Job Responsibility:

Work in clinical telephone queue for 3 to 4 hours a day working with providers to secure additional information for prior authorization review
Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render determination/recommendation along the continuum of care
Communicates with providers and other parties to facilitate care/treatment
Identifies members for referral opportunities to integrate with other products, services and/or programs
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

Requirements:

1 year of varied UM (utilization management) experience within an outpatient setting, concurrent review or prior authorization
5 years of a variety clinical experience required including acute care, home health, or long-term care
5 years demonstrated ability to make thorough, independent decisions using clinical judgement
A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all noncompact states
Required to use a residential broadband service with internet speeds of at least 25 mbps/3mbps
Associate degree in nursing RN required

Nice to have:

1+ years Managed Care (MCO) preferred
1+ years demonstrated experience working in a high-volume clinical call center environment
1 year of varied UM (utilization management) experience within an inpatient, concurrent review or prior authorization
Remote work experience
BSN preferred

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
August 27, 2025

Expiration:
September 04, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Utilization Management Nurse Consultant