Utilization Management Nurse Consultant, Specialty Spine Team (Remote)
Schedule: Monday-Friday, 8:00 AM-5:00 PM EST/CST, with rotating weekend and holiday coverage
Are you an experienced RN with a passion for clinical review, evidence-based decision-making, and specialty spine care? Join our Utilization Management (UM) Spine Team and play a critical role in ensuring members receive high-quality, medically necessary care.
In this role, you'll review spine-related authorization requests, evaluate clinical documentation using established medical necessity guidelines, collaborate with providers and Medical Directors, and support timely, accurate coverage determinations. This is an excellent opportunity for nurses who thrive in a fast-paced managed care environment and enjoy combining clinical expertise with analytical decision-making.
What You'll Do
- Review prior authorization requests for spine-related procedures and services
- Apply evidence-based criteria, including MCG guidelines and clinical policies
- Assess clinical records, treatment plans, and provider documentation
- Partner with providers, Medical Directors, and health plan teams to support appropriate care decisions
- Ensure compliance with regulatory and organizational requirements
- Meet quality, productivity, and turnaround time standards while contributing to process improvements
Required Qualifications
- Active, unrestricted Registered Nurse (RN) license in state of residence
- Willingness to obtain additional state licensure as needed
- 3-5+ years of clinical nursing experience
- Strong knowledge of medical necessity review and evidence-based practice
- Excellent critical thinking, communication, and documentation skills
Preferred Qualifications
- Experience in orthopedics, spine surgery, neurosurgery, pain management, rehabilitation, or utilization management
- Managed care, health plan, or payer experience
- Knowledge of Medicaid programs and authorization requirements
- Experience with MCG, Clinical Policy Bulletins, MedCompass, QNXT, or similar UM platforms
- Eastern or Central Time Zone preferred
- BSN 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: 40
Time Type: Full time
Pay Range
The typical pay range for this role is: $29.10 - $62.32