Utilization Management Nurse Consultant

CVS Health Careers

. Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members .

Posted 11/3/2026full-timeRemote • New Jersey • United StatesMid-LevelSenior💰 $26 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare service coordination, clinical assessment, and utilization management, with a strong focus on effective communication and collaboration with providers and members. Proficient in navigating multiple IT platforms and ensuring compliance with healthcare guidelines and regulations.

Highest-signal resume keywords

Registered Nurse LicensureMed/Surg ExperienceUtilization ManagementMicrosoft Office ApplicationsInpatient Hospital Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCoverage DeterminationHealthcare Service CoordinationClinical Criteria ApplicationBenefit ManagementTechnical TroubleshootingEHR Portal NavigationVPN LoginMultiple Monitor UsageInternet Speed Compliance

Soft Skills

Effective CommunicationCollaborationAdaptabilityProblem-SolvingAttention to Detail

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR SystemsTeams Messaging

Certifications & Qualifications

Active RN Licensure

Industry Keywords

Healthcare ServicesUtilization ManagementHIPAA ComplianceClinical GuidelinesPatient Care

About the role

Key responsibilities & impact

Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members
Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment
Render coverage determinations and recommendations across the continuum of care
Communicate with providers and other parties to facilitate care and treatment
Identify members for referral opportunities involving other products, services, and programs
Identify opportunities to promote healthcare-service quality, effectiveness, and benefit utilization
Consult with and advise internal and external constituents on utilization and benefit management
Work a schedule that may include weekends, holidays, and evening hours in a 24/7 utilization-management operation
Work 40 hours per week

Requirements

What you’ll need

3–5 years of Med/Surg experience
3+ years of experience as an RN
1+ year of inpatient hospital experience
Active, current, and unrestricted RN licensure in state of residence
Ability to work in multiple IT platforms/systems
1+ year of experience with Microsoft Office applications (Outlook, Teams, Excel)
Associates Degree required
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
Ability to use multiple monitors and navigate multiple applications simultaneously
Ability to use 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 screens, managing strong passwords, and recognizing suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills as the workplace evolves

Benefits

Comp & perks

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