UM Nurse Consultant | Specialty UM - Spine

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 prioritize 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. Utilization Management Nurse Consultant, Specialty Spine Team (Remote) Schedule Monday-Friday, 8:00 AM-5:00 PM EST/CST, with rotating weekend and holiday coverage Are you an experienced RN with a passion for clinical review, evidence-based decision-making, and specialty spine care? Join our Utilization Management (UM) Spine Team and play a critical role in ensuring members receive high-quality, medically necessary care. In this role, you'll review spine-related authorization requests, evaluate clinical documentation using established medical necessity guidelines, collaborate with providers and Medical Directors, and support timely, accurate coverage determinations. This is an excellent opportunity for nurses who thrive in a fast-paced managed care environment and enjoy combining clinical expertise with analytical decision-making. What You'll Do Review prior authorization requests for spine-related procedures and services Apply evidence-based criteria, including MCG guidelines and clinical policies Assess clinical records, treatment plans, and provider documentation Partner with providers, Medical Directors, and health plan teams to support appropriate care decisions Ensure compliance with regulatory and organizational requirements Meet quality, productivity, and turnaround time standards while contributing to process improvements Required Qualifications Active, unrestricted Registered Nurse (RN) license in state of residence Willingness to obtain additional state licensure as needed 3-5+ years of clinical nursing experience Strong knowledge of medical necessity review and evidence-based practice Excellent critical thinking, communication, and documentation skills Preferred Qualifications Experience in orthopedics, spine surgery, neurosurgery, pain management, rehabilitation, or utilization management Managed care, health plan, or payer experience Knowledge of Medicaid programs and authorization requirements Experience with MCG, Clinical Policy Bulletins, MedCompass, QNXT, or similar UM platforms Eastern or Central Time Zone preferred BSN preferred Education Associate Degree in Nursing (ASN) required Bachelor of Science in Nursing (BSN) preferred Join a team dedicated to clinical excellence, consistency, and quality outcomes while making a meaningful impact on members' care journeys. 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 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted. A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, 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 recognize suspicious emails 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: $29.10 - $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 program 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 programs, 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: 10/17/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr