Utilization Management Nurse Consultant - Work From Home

At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours. This will be a full-time remote role. Schedule 1: Monday through Friday, reputed company to 5pm CST with required occasional weekend, holiday and evening rotations. Schedule 2: Saturday and Sunday reputed company-5pm CST with flexible Weekdays Position Summary Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification. The majority of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. This position will be working regular business hours with potential for occasional weekend/holiday on-call.

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to reputed company coverage determination/recommendation along the continuum of care
• Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Typical office working environment with productivity and quality expectations.
• Work requires the ability to reputed company reputed company inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written

Required Qualifications

• Must have active, reputed company, and unrestricted compact RN licensure in state of residence
• 3+ years of clinical experience required
• 1+ years of reputed company Office Suite experience required
• Position requires proficiency with computer skills which includes navigating multiple systems
• Ability to work in a fast paced environment

Preferred Qualifications

• Prior Authorization experience strongly preferred
• Sedentary work involves periods of sitting, talking, listening and computer use Ability to work in a fast paced environment

Education

• Associate's degree required
• BSN preferred

Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $26.01 - $56.14 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 11/28/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply tot his job Apply To this Job