Utilization Management Nurse Consultant – Medical Review

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Execute, coordinate, oversee, and assess medical review cases.

• Utilize clinical criteria, guidelines, plan language, and policy details to make medical determinations.

• Approve procedures and services or initiate referrals to the Medical Director as necessary.

• Employ critical thinking, evidence-based criteria, and clinical practice guidelines.

• Provide training, mentorship, and feedback to new nurse reviewers, business partners, or vendors.

• Cross-train to conduct reviews across various case types.

• Suggest, test, and implement improvements in processes, audits, and technology.

• Operate independently to achieve quality and metric goals.

⛳️ Requirements

• A valid, unrestricted RN license in the state of residence with multistate/compact licensure privileges.

• Capability to obtain licensure in non-compact states as required.

• At least 3 years of clinical experience.

• 5 years of proven ability to make comprehensive independent decisions using clinical judgment.

• 5 years of proficient use of equipment, including phone, computer, and clinical documentation systems.

• 1+ year of experience in Utilization Review Management and/or Medical Management.

• Attendance at mandatory 3-week training, Monday–Friday, 8:30am–5:00pm EST, with full participation required.

• An Associate's degree in nursing (RN) is required.

• Preferred experience in interpreting plan language, policies, and benefits to assess medical necessity.

• Experience with MCG Milliman, CPB, or other criteria guideline applications is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.