Utilization Management Nurse Consultant

CVS Health Careers

. Review clinical information and apply evidence-based criteria to make coverage and authorization determinations .

Posted 11/6/2026full-timeRemote • Pennsylvania • United StatesJuniorMid-Level💰 $26 - $75 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical decision-making and utilization management, with a strong focus on patient advocacy and care coordination. Proficient in navigating multiple documentation systems and collaborating effectively with interdisciplinary teams to enhance patient outcomes.

Highest-signal resume keywords

Active RN LicenseUtilization Management Experience2+ Years Acute Care ExperienceMicrosoft Office 365 ProficiencyStrong Multitasking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Decision-MakingCare CoordinationCase ManagementEvidence-Based Criteria ApplicationDocumentation Proficiency

Soft Skills

Strong Communication SkillsCritical ThinkingOpenness to LearningMultitasking Ability

Tools & Technologies

EHR PortalsVPN AccessMicrosoft Office 365Google WorkspaceMultiple Monitors

Certifications & Qualifications

Active RN LicenseAssociate Degree in NursingBSN Preferred

Industry Keywords

Healthcare UtilizationPatient AdvocacyManaged CareHIPAA ComplianceInterdisciplinary Collaboration

About the role

Key responsibilities & impact

Review clinical information and apply evidence-based criteria to make coverage and authorization determinations
Collaborate with physicians, providers, and interdisciplinary teams to support quality patient outcomes
Identify opportunities for care coordination, case management, and other healthcare programs
Promote effective healthcare utilization and member-centered care
Serve as a clinical resource and partner for internal and external stakeholders
Work within a 24/7 Utilization Management operation
Document work using multiple systems and documentation platforms
Support patient advocacy, critical thinking, healthcare decision-making, and improved member experiences

Requirements

What you’ll need

Active, unrestricted RN license in your state of residence
2+ years of Registered Nurse experience in an adult acute care or critical care setting
Associate Degree in Nursing (ADN)
2+ years of Med-Surg or specialty clinical experience preferred
Utilization Management or Managed Care experience preferred
BSN preferred
Candidates located in the Eastern Time Zone are strongly preferred
Ability to work evenings, weekends, and holidays as schedules may vary in a 24/7 operation
Strong multitasking and communication skills
Computer-based work requiring navigation of multiple systems and documentation platforms
Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload
Quiet, secure, private, designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Ability to use multiple monitors and navigate multiple applications
Ability to communicate through 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, secure devices, manage strong passwords, and recognize 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

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 including keyboard, monitor, computer, and headset