Job Overview: CVS Health is seeking a highly skilled Utilization Management Nurse Consultant to join our dynamic team in a fully remote capacity. In this critical role, you will play a pivotal part in optimizing healthcare delivery by assessing clinical information, applying evidence-based criteria, and making timely decisions on patient care authorizations. This position offers the flexibility of working from anywhere, allowing you to balance professional excellence with personal life while contributing to innovative healthcare solutions at one of America's leading health companies. Key Responsibilities: Conduct thorough clinical reviews of medical records, physician orders, and treatment plans to determine medical necessity and appropriateness of care. Collaborate with healthcare providers, case managers, and internal teams to approve, modify, or deny service requests based on established guidelines such as InterQual or Milliman Care Guidelines. Document all utilization review activities accurately in electronic systems, ensuring compliance with regulatory standards including CMS, NCQA, and state-specific requirements. Provide education and consultation to providers on utilization management processes, alternative care options, and cost-effective treatments. Monitor ongoing cases for continued stay reviews, discharges, and transitions to lower levels of care. Participate in quality improvement initiatives, peer reviews, and appeals processes to uphold high standards of patient care and operational efficiency. Stay current with evolving healthcare policies, payer contracts, and clinical best practices to support data-driven decision-making. Required Qualifications: Active, unrestricted Registered Nurse (RN) license in good standing; a BSN is strongly preferred. Minimum of 3-5 years of recent clinical nursing experience in areas such as acute care, home health, or managed care. Prior experience in utilization review, case management, or discharge planning is highly desirable. Proficiency with electronic medical records (EMR) systems and Microsoft Office suite. Strong knowledge of medical terminology, anatomy, pharmacology, and disease processes. Excellent communication skills, both verbal and written, with the ability to interact professionally with diverse stakeholders. Skills: Exceptional critical thinking and clinical judgment to analyze complex cases efficiently. Superior organizational abilities to manage high-volume caseloads while meeting turnaround time (TAT) requirements, often within 24-72 hours. Proficiency in applying clinical criteria sets and navigating payer authorization portals. Strong interpersonal skills for building rapport with physicians, nurses, and patients. Analytical mindset with attention to detail for accurate documentation and auditing. Adaptability to remote work tools like secure VPNs, teleconferencing platforms (e.g., Zoom, Teams), and utilization management software (e.g., InterQual, Epic). Commitment to confidentiality and ethical standards in handling protected health information (PHI). Company Info: CVS Health, a Fortune 10 company, is transforming the future of healthcare through integrated pharmacy services, MinuteClinic locations, and innovative health insurance solutions via Aetna. With over 300,000 colleagues nationwide, we prioritize diversity, equity, and inclusion to serve 100 million+ customers. Our mission is to make quality care more accessible, affordable, and simpler for all. Benefits: Competitive salary with performance-based incentives. Comprehensive health, dental, and vision coverage starting day one. Generous 401(k) match, paid time off, parental leave, and employee stock purchase plan. Robust wellness programs, tuition reimbursement up to $5,250 annually, and mental health support. Fully remote setup including home office stipend and top-tier technology equipment. Growth Opportunities: Advance your career through CVS Health's leadership development programs, clinical ladder promotions, and certifications like CCM or CPUM reimbursement. Access mentorship, cross-functional projects, and internal mobility to roles in care management, population health, or clinical operations leadership. Join a supportive culture with ongoing training to thrive in evolving healthcare landscapes.