Job Overview: CVS Health is seeking a dedicated Utilization Management Nurse Consultant to join our dynamic team in a fully remote capacity. In this critical role, you will apply your clinical nursing expertise to evaluate medical necessity, review treatment plans, and facilitate optimal patient care coordination across various healthcare settings. As a key contributor to our utilization management team, you will help ensure that services are clinically appropriate, cost-effective, and aligned with evidence-based guidelines, ultimately supporting better health outcomes for our members. 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, deny, or modify requests based on established criteria such as InterQual or Milliman guidelines. Provide education and feedback to providers on utilization management processes and best practices. Document all review activities accurately in our proprietary systems, ensuring compliance with regulatory standards including CMS, NCQA, and state-specific requirements. Monitor trends in utilization patterns, identify potential over- or under-utilization, and recommend process improvements. Participate in peer reviews, appeals processes, and quality assurance initiatives to uphold high standards of care delivery. Stay current with evolving healthcare policies, clinical guidelines, and industry best practices to inform decision-making. Required Qualifications: Active, unrestricted RN license in good standing; minimum of 3-5 years of recent clinical nursing experience in areas such as acute care, case management, or utilization review. Bachelor's degree in Nursing (BSN) preferred; Associate's degree with relevant experience considered. Prior experience with utilization management, prior authorization, or concurrent review processes strongly preferred. Proficiency in electronic medical records (EMR) systems and Microsoft Office suite. Strong knowledge of medical terminology, anatomy, physiology, and disease processes. Excellent organizational skills with the ability to manage high-volume caseloads efficiently. Skills: Exceptional critical thinking and clinical decision-making abilities. Outstanding communication skills, both verbal and written, for interacting with diverse stakeholders. Detail-oriented with a commitment to accuracy and compliance. Ability to work independently in a remote setting while collaborating effectively in a virtual team environment. Proficiency in data analysis and reporting tools. Adaptability to fast-paced environments and changing priorities. Company Info: CVS Health, a Fortune 10 company, is a leading healthcare innovator dedicated to making quality care more accessible, affordable, and equitable for all. With a vast network of pharmacies, clinics, and health services, we serve millions of customers nationwide, combining clinical expertise with advanced technology to transform the healthcare experience. Benefits: Competitive salary and performance-based incentives. Comprehensive health, dental, and vision insurance with low premiums. Generous 401(k) matching, paid time off, and parental leave. Remote work setup including home office stipend and IT support. Professional development opportunities, tuition reimbursement, and wellness programs. Employee stock purchase plan and recognition programs. Growth Opportunities: Advance your career within CVS Health's expansive organization through leadership development programs, specialized certifications in case management (CCM) or utilization review, and cross-functional projects. Join a supportive culture that values innovation, diversity, and employee well-being, with clear paths to senior consultant, manager, or director roles.