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 11/11/2026full-timeRemote • Ohio • United StatesJuniorMid-Level💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare service coordination, clinical assessment, and utilization management while ensuring compliance with HIPAA guidelines. Proficient in leveraging technology for effective communication and documentation in a remote work environment.

Highest-signal resume keywords

Registered Nurse LicensureClinical AssessmentUtilization ManagementMicrosoft Office 365Effective Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Criteria ApplicationCoverage DeterminationHealthcare Service Quality PromotionTechnical TroubleshootingComputer ProficiencyMultitaskingPrioritizationDocument InspectionEHR Portal NavigationVPN Login

Soft Skills

Effective Verbal CommunicationEffective Written CommunicationAdaptabilityCollaborationInterpersonal Skills

Tools & Technologies

Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPointGoogle WorkspaceSecure Computer SystemsVirtual Meeting Platforms

Certifications & Qualifications

Active RN LicensureAssociates Degree

Industry Keywords

Healthcare ServicesBenefit ManagementHIPAA ComplianceAcute CareCritical CareRemote WorkProductivity ExpectationsQuality Expectations

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 judgment to render coverage determinations or recommendations
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 provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
Work in a typical office environment with productivity and quality expectations
Perform sedentary work involving extended sitting, telephone conversations, listening, and computer typing

Requirements

What you’ll need

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Active, current and unrestricted RN licensure in state of residence
Ability to work weekends, holidays, and evening hours in a 24/7 operation
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously
Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals, secure computer systems, manage strong passwords, and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Direct/hardwired internet connection to modem/router within 7 feet of computer
Minimum internet speed of 50 Mbps download and 5 Mbps upload
Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently residing
Associates Degree required
Ability to obtain and adhere to required work-from-home internet and workspace requirements
Ability to perform close inspection of handwritten and computer-generated documents and PC monitor
Computer proficiency, keyboarding, multitasking, prioritization, and effective adaptation to a fast-paced changing environment
Effective verbal and written communication skills

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 eligibility
Company-provided equipment (keyboard, monitor, computer, headset, etc.)