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

Core Competencies

Role fit

Core Competencies

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

Highest-signal resume keywords

Active RN License2+ Years RN Experience in Acute CareAssociate Degree in NursingProficiency in Microsoft Office 365Effective Verbal and Written Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationUtilization ManagementCoverage DeterminationsClinical JudgmentMultitaskingKeyboarding ProficiencyTroubleshooting Technical IssuesDocument InspectionEHR Navigation

Soft Skills

AdaptabilityPrioritizationCommunicationCollaborationProblem-Solving

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR PortalsTeams Messaging

Certifications & Qualifications

Active RN License

Industry Keywords

Healthcare ServicesBenefit ManagementHIPAA ComplianceClinical GuidelinesAcute CareCritical CareRemote WorkProductivity ExpectationsQuality AssuranceReferral Opportunities

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 to render coverage determinations or recommendations across the continuum of care
Communicate with providers and other parties to facilitate care and treatment
Identify members for referral opportunities to other products, services, and programs
Identify opportunities to promote healthcare-service quality and effective benefit utilization
Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
Work within a typical office environment with productivity and quality expectations while working remotely

Requirements

What you’ll need

Active, unrestricted RN license in your state of residence
2+ years of RN experience in adult acute care or critical care settings
Associate Degree in Nursing required
Preference for candidates in CST or EST time zones
Flexibility for evenings, weekends, and holidays in a 24/7 operation
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
Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor
Ability to sit for extended periods, talk on the telephone, and type on a computer
Ability to multitask, prioritize, and adapt to a fast-paced changing environment
Proficiency navigating multiple computer systems and keyboarding
Effective verbal and written communication skills
Ability to use multiple monitors and applications simultaneously
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace tools
Ability to log in to secure systems such as VPN and EHR portals, follow computer security practices, and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently

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.)