Quality Management Nurse RN Consultant

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritise safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. RN Utilisation Management Nurse Consultant (Medicare – Joint Procedures) Remote | Full-Time | Monday–Friday (9:00 am to 5:30 pm in your time zone, with occasional evenings/holidays) Are you an experienced Registered Nurse looking to make an impact beyond the bedside? Join a collaborative Utilisation Management team where your clinical expertise helps ensure members receive the right care at the right time. What You’ll Do Review and assess clinical information for Medicare precertification (joint procedures) Apply evidence-based criteria and clinical judgement to make coverage determinations Collaborate with providers and care teams to coordinate appropriate treatment plans Identify opportunities to improve care quality and optimise healthcare utilisation Support care integration by connecting members to additional programmes and services Serve as a clinical resource to internal and external partners What You Bring - REQUIRED Active, unrestricted RN licence in the state of residence 3+ years of RN experience 1+ year of Med/Surg experience Proficiency in Microsoft Office (Outlook, Teams, Excel) Associate degree in nursing Nice to Have Utilisation Management or Prior Authorization experience Managed care and/or Medicare experience MedCompass or similar system experience Ambulatory surgery background BSN Why Join Us? Consistent weekday schedule (with some flexibility for a 24/7 operation) Opportunity to use your clinical expertise in a non-bedside role Collaborative, mission-driven team focused on quality care Work from Home Requirements You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbps download and 3 mbps upload. WiFi and satellite internet are not permitted. A quiet, secure and private designated home virtual work location, free from distractions, tidy and organised, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours. Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live. The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time). If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements. Technical and Logistical Requirements Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency. Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings. Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace). Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognise suspicious e mails or links. Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues. Future Growth: Openness to learning new skills in the future as the workplace environment evolves. Anticipated Weekly Hours: 40 Time Type: Full time Pay Range The typical pay range for this role is: $26.01 - $62.32. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive programme in addition to the base 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programmes, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 10/22/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr