Utilization Management Nurse Consultant – Medical Review

Job not on LinkedIn

🔥 8 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Implement, coordinate, monitor, and evaluate medical review cases • Apply clinical criteria, guidelines, plan language, and policy specifics to render medical determinations • Use critical thinking, evidence-based clinical criteria, and clinical practice guidelines to authorize procedures/services or initiate Medical Director referrals • Assist management with training, mentoring, and providing feedback to new nurse reviewers, business partners, or vendors • Cross-train to perform reviews of multiple case types • Recommend, test, and implement process, audit, and technology improvements • Work independently to meet quality and metric expectations • Collaborate with providers to help members receive timely, medically necessary care

🎯 Requirements

• Active, unrestricted RN license in the state of residence with multistate/compact licensure privileges • Ability to obtain licensure in non-compact states as needed • Minimum 3 years of clinical experience • 5 years demonstrated to make thorough independent decisions using clinical judgment • 5 years of proficient equipment use experience, including phone, computer, and clinical documentation systems • 1+ year of Utilization Review Management and/or Medical Management experience • Mandatory 3-week training attendance, Monday–Friday, 8:30am–5:00pm EST, with 100% participation • Associate's degree in nursing (RN) required • Experience interpreting Plan Language, Policies, and Benefits to determine medical necessity preferred • MCG Milliman, CPB, or other criteria guideline application experience preferred

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume