Utilization Management Nurse Consultant

CVS Health Careers

. Review clinical cases and make coverage determinations using evidence-based guidelines .

Posted 11/9/2026full-timeRemote • Idaho • United StatesMid-LevelSenior💰 $26 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates strong clinical assessment and decision-making skills in a remote utilization management role, with a focus on Medicare complex spine cases. Proficient in Microsoft Office applications and capable of navigating secure systems while ensuring compliance with HIPAA guidelines.

Highest-signal resume keywords

Active RN License3+ Years RN ExperienceUtilization Management ExperienceClinical Assessment SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical JudgmentDecision-Making SkillsUtilization ManagementPrior AuthorizationAmbulatory Surgery ExperienceMed/Surg ExperienceEHR NavigationTechnical Issue ResolutionInternet Connection ManagementHIPAA Compliance

Soft Skills

CollaborationCommunicationOpenness to LearningProblem-Solving

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR PortalsMultiple Monitors

Certifications & Qualifications

RN LicenseBSN Preferred

Industry Keywords

Managed CareMedCompassEvidence-Based GuidelinesCare Quality ImprovementMember Outcomes

About the role

Key responsibilities & impact

Review clinical cases and make coverage determinations using evidence-based guidelines
Collaborate with providers and care teams to coordinate appropriate treatment
Apply clinical judgment to utilization and benefit management decisions
Identify opportunities to improve care quality and member outcomes
Serve as a clinical resource across internal and external stakeholders
Work in a remote, non-bedside utilization management role focused on Medicare complex spine cases

Requirements

What you’ll need

Active, unrestricted RN license in the state of residence
3+ years of RN experience, including 1+ year in Med/Surg
Strong clinical assessment and decision-making skills
Experience with Microsoft Office (Outlook, Teams, Excel)
Ability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone; schedules may include holidays and evening hours
Associate Degree in Nursing
Must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 25 Mbps download and 3 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Must provide own workspace furniture, such as a desk or standing desk
Comfortable setting up and using multiple monitors and navigating multiple applications
Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals
Ability to follow computer security practices, including locking the screen, managing strong passwords, and recognizing suspicious emails or links
Ability to resolve common technical issues independently and contact IT when needed
Openness to learning new skills as the workplace evolves
Utilization Management or Prior Authorization experience preferred
Managed care background preferred
Familiarity with MedCompass preferred
Ambulatory surgery experience preferred
BSN preferred

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to base pay
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
Company-provided equipment (keyboard, monitor, computer, headset, etc.)