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 | Weekday Schedule

Are you a Registered Nurse looking to leverage your clinical expertise in a non-bedside role? Join our team and help ensure members receive high-quality, appropriate care through evidence-based utilization management and care coordination.

Position Summary

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. 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. This position offers an opportunity to leverage your nursing experience in a non-bedside environment while making a meaningful impact on member care.

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

Required Qualifications

• 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.

Education:

• Associate degree required.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

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.

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.

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

We anticipate the application window for this opening will close on: 11/18/2026

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