Job Overview Join CVS Health as a Utilization Management Nurse Consultant - Medical Review in this fully remote role. You will play a pivotal role in reviewing medical necessity, authorizing services, and optimizing healthcare delivery for Aetna members. This position offers the flexibility of working from anywhere while contributing to innovative health solutions at one of America's leading healthcare companies. Key Responsibilities Conduct thorough clinical reviews of medical records, physician notes, and treatment plans to determine medical necessity and appropriateness of care. Collaborate with healthcare providers, physicians, and internal teams to facilitate prior authorizations, concurrent reviews, and appeals processes. Apply evidence-based clinical guidelines such as InterQual or MCG criteria to ensure compliance with regulatory standards including CMS, NCQA, and state regulations. Document decisions accurately in utilization management systems, maintaining detailed rationales for approvals, denials, or modifications. Monitor length of stay, level of care, and discharge planning to promote cost-effective, quality outcomes. Participate in peer reviews, case conferences, and educational initiatives to enhance team knowledge and performance. Identify and escalate complex cases involving high-risk patients or potential quality issues to senior clinicians or medical directors. Required Qualifications Active, unrestricted Registered Nurse (RN) license in good standing. Minimum of 3-5 years of recent clinical nursing experience, preferably in acute care, case management, or utilization review. Strong knowledge of managed care principles, DRG systems, ICD-10 coding, and HCPCS. Proficiency with electronic medical records (EMR) and UM software platforms. Excellent organizational skills with the ability to manage high-volume caseloads under tight deadlines. Bachelor's degree in Nursing (BSN) preferred; Associate's degree (ADN) with relevant experience considered. Skills Exceptional critical thinking and decision-making abilities to analyze complex clinical data. Superior communication skills, both verbal and written, for interacting with diverse stakeholders. Proficiency in Microsoft Office Suite, including Excel for reporting and data analysis. Strong attention to detail and commitment to accuracy in documentation. Ability to work independently in a remote environment while thriving in a collaborative virtual team setting. Familiarity with telehealth trends and value-based care models is a plus. Company Info CVS Health, headquartered in Woonsocket, Rhode Island, is a Fortune 10 company revolutionizing health care through integrated pharmacy services, MinuteClinic locations, and Aetna insurance. With over 300,000 colleagues, we serve millions annually, focusing on lowering costs, enhancing access, and improving outcomes via digital innovations like HealthHUBs and virtual care. Benefits Comprehensive benefits package including medical, dental, and vision coverage starting day one. Generous 401(k) with company match, paid time off, parental leave, and employee stock purchase plan. Tuition reimbursement, wellness programs, and flexible remote work options. Access to CVS Health's employee assistance program and mental health resources. Growth Opportunities Advance your career through CVS Health's robust development programs, including leadership tracks, certifications in case management (CM), and utilization review specialties. Opportunities to transition into senior consultant, manager, or director roles. Participate in cross-functional projects driving healthcare innovation and gain exposure to national initiatives.