Utilization Management Nurse Consultant

Are you a Registered Nurse ready to make an impact beyond the bedside? Join our team and use your clinical expertise to ensure members receive the right care at the right time. Utilization Management Nurse Consultant, Clinical Precertification RN (Medicare- Complex Spine Team). Remote | Full-Time | Weekday Schedule.

Responsibilities

Review clinical cases and make coverage determinations using evidence-based guidelines; Collaborate with providers and care teams to coordinate appropriate treatment; Apply clinical judgment to support utilization and benefit management decisions; Identify opportunities to improve care quality and member outcomes; Serve as a clinical resource across internal and external stakeholders

Requirements

Active, unrestricted RN license in the state of residence; 3+ years of RN experience, including 1+ year in Med/Surg; Strong clinical assessment and decision-making skills; Experience with Microsoft Office (Outlook, Teams, Excel); Ability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone, with schedules that include holidays and evening hours; Associate Degree in Nursing; Direct/hardwired internet connection to a modem/router within 7 feet of your computer with minimum 25 mbps download and 3 mbps upload (WiFi and satellite not permitted); Quiet, secure and private designated home work location; Work within the state and city where you currently live; Ability to use multiple monitors and applications simultaneously; Ability to communicate via email, calendar invites, Teams and virtual meetings; Experience with Microsoft Office 365 or similar (Google Workspace); Ability to log in to secure systems (VPN, EHR portal) and recognize suspicious emails or links; Ability to resolve common technical issues independently

Nice to have

Utilization Management or Prior Authorization experience; Managed care background; Familiarity with MedCompass; Ambulatory surgery experience; BSN preferred

Benefits

Medical, dental, and vision coverage; Paid time off; Retirement savings options; Wellness programs; Other resources based on eligibility; Eligible for CVS Health bonus, commission or short-term incentive program