Pensacola, FL · Remote
$29.10 - $62.32/hr
This includes reviewing written clinical records. - Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical ...
Pensacola, FL · Remote
$29.10 - $62.32/hr
This includes reviewing written clinical records. - Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical ...
$18.31 - $22.01
2% of jobs
$22.01 - $25.72
9% of jobs
$28.25 is the 25th percentile. Wages below this are outliers.
$25.72 - $29.42
21% of jobs
The median wage is $32.42 / hr.
$29.42 - $33.12
23% of jobs
$33.12 - $36.82
13% of jobs
$39.70 is the 75th percentile. Wages above this are outliers.
$36.82 - $40.53
10% of jobs
$40.53 - $44.23
8% of jobs
$44.23 - $47.93
5% of jobs
$47.93 - $51.64
5% of jobs
$51.64 - $55.34
2% of jobs
$55.34 - $59.04
2% of jobs
$18
$36
$59
To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.
A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.
A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.
$29.10 - $62.32/hr
Full-time
Medical, Dental, Vision, Retirement, PTO
Posted 14 days ago
5.8
Based on 4,270 frontline employees who took The Breakroom Quiz
78th of 101 rated pharmacies
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 ourselvesaccountable 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.
Position Summary
Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours.
This role is work from home anywhere in the state of Florida. Applicant must reside in Florida.
As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.
- Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
- Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage
determination/recommendation/discharge planning along the continuum of care
- Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
- Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
- Identifies members who may benefit from care management programs and facilitates referral
- Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
Required Qualifications
-3+ years of clinical practice experience in an inpatient setting required
-Must have active current and unrestricted RN licensure in state of Florida
-Willingness to obtain additional state licenses as needed (paid for by company)
- Must reside in Florida
Preferred Qualifications
- Previous Utilization Management and/or Managed Care experience preferred
- Discharge planning experience
Education
Associate's degree required
BSN preferred
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$29.10 - $62.32This 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.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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Health care and social assistance and retail
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