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 11/9/2026full-timeRemote • Texas • United StatesMid-LevelSenior💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Prior Authorization processes, leveraging clinical judgment and guidelines to facilitate healthcare services. Proficient in Microsoft Office applications and maintaining compliance with HIPAA regulations in a remote work environment.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceMed/Surg ExperienceMicrosoft Office ProficiencyMedCompass Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCoverage DeterminationHealthcare Service CoordinationClinical Criteria ApplicationMedicare Utilization ManagementData Security MaintenanceTechnical TroubleshootingMultiple Application NavigationEHR Portal AccessAmbulatory Surgery Experience

Soft Skills

Effective CommunicationCollaboration with ProvidersProblem-Solving

Tools & Technologies

Microsoft Office 365Google WorkspaceVPN AccessEHR SystemsMedCompass

Certifications & Qualifications

Active RN LicensureAssociates DegreeBSN Preferred

Industry Keywords

Managed CareHealthcare ServicesClinical GuidelinesHIPAA ComplianceBenefit Utilization

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
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 and effective benefit utilization
Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
Perform Medicare clinical predetermination and utilization management activities

Requirements

What you’ll need

3+ years of experience as a Registered Nurse
Active, current and unrestricted RN licensure in state of residence
1+ years of Med/Surg experience
1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
Willingness and ability to work Monday through Friday, 9:00am to 5:30pm Eastern or Central time, with occasional holiday rotation; schedules may include holidays and evening hours
Prior Authorization or Utilization Management experience preferred
Managed care experience preferred
Experience using MedCompass preferred
Ambulatory surgery experience preferred
Associates degree required
BSN preferred
Direct/hardwired internet connection to modem/router within 7 feet of 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 residing
Ability to use multiple monitors and navigate multiple applications
Experience with Microsoft Office 365 applications or similar Google Workspace tools
Ability to log in to secure systems such as VPN and EHR portals
Ability to maintain computer and data security
Ability to troubleshoot common technical issues independently

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
Company-provided equipment (keyboard, monitor, computer, headset, etc.)
CVS Health bonus, commission or short-term incentive program eligibility