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 (RN)
Remote | Prior Authorization | Utilization Management
Are you an experienced RN with utilization management or prior authorization experience looking to make an impact beyond bedside care? Join our team and help ensure members receive timely, appropriate, and cost-effective healthcare services through evidence-based clinical review and decision-making.
What You'll Do
- Review prior authorization requests across a broad range of medical specialties
- Evaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements
- Apply InterQual, MCG, or similar clinical criteria to support authorization determinations
- Collaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality care
- Ensure compliance with health plan policies, regulatory requirements, and clinical standards
- Manage a high-volume caseload while meeting productivity, quality, and turnaround-time expectations
- Support effective healthcare utilization and positive member outcomes
WHAT YOU BRING - REQUIRED
- Active, unrestricted multi-state RN license in your state of residence, or the ability to obtain and maintain multi-state.
- Ability to obtain and maintain additional state licensure as needed
- 3+ years of clinical nursing experience
- 2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experience
- Experience reviewing medical records and determining medical necessity
- Experience using InterQual, MCG, or similar clinical decision-support tools
- Strong clinical assessment, critical thinking, and decision-making skills
- Excellent verbal and written communication skills
- Ability to manage multiple priorities in a fast-paced environment
- Proficiency with electronic medical records and utilization management systems
Preferred Qualifications
- BSN preferred
- Experience supporting Medicaid, Medicare, or Commercial Health Plan populations
- Prior Authorization experience within a health plan or managed care organization
- Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests
- Knowledge of state and federal utilization management regulations
- Experience working remotely
- Louisiana residency preferred
- Experience supporting Louisiana Medicaid populations preferred
Education
- Associate Degree in Nursing (ASN) required
- Bachelor of Science in Nursing (BSN) preferred
Work from Home Requirements:
- You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
- A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
- Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
- The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
- If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
Technical and Logistical Requirements:
- Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
- Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
- Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
- Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
- Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
- Future Growth: Openness to learning new skills in the future as the workplace environment evolves
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$26.01 - $56.14This 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.
Skills Required
- Active, unrestricted multi-state RN license in the state of residence, or ability to obtain and maintain a multi-state license
- Ability to obtain and maintain additional state licensure as needed
- At least 3 years of clinical nursing experience
- At least 2 years of utilization management, prior authorization, managed care, case management, or clinical review experience
- Experience reviewing medical records and determining medical necessity
- Experience using InterQual, MCG, or similar clinical decision-support tools
- Strong clinical assessment, critical thinking, and decision-making skills
- Excellent verbal and written communication skills
- Ability to manage multiple priorities in a fast-paced environment
- Proficiency with electronic medical records and utilization management systems
- Associate Degree in Nursing (ASN)
- Bachelor of Science in Nursing (BSN)
- Experience supporting Medicaid, Medicare, or commercial health plan populations
- Prior authorization experience within a health plan or managed care organization
- Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests
- Knowledge of state and federal utilization management regulations
- Experience working remotely
- Louisiana residency
- Experience supporting Louisiana Medicaid populations
- Direct or hardwired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload
- Quiet, secure, private, HIPAA-compliant designated home workspace
- Ability to navigate multiple monitors and applications simultaneously
- Experience with Microsoft Office 365 applications or similar Google Workspace tools
- Ability to use secure systems, VPN, EHR portals, strong passwords, and security practices
- Ability to troubleshoot common technical issues independently
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
CVS Health Insights
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
