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