Utilization Management Nurse Consultant

CVS Health Careers

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

Posted 10/30/2026full-timeRemote • South Carolina • United StatesJuniorMid-Level💰 $26 - $75 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment and care coordination, utilizing evidence-based criteria to optimize healthcare outcomes. Proficient in communication and technology use to support interdisciplinary collaboration and manage healthcare resources effectively.

Highest-signal resume keywords

Active RN License2+ Years RN ExperienceUtilization Management ExperienceMicrosoft Office 365 ProficiencyClinical Judgment

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationEvidence-Based Criteria ApplicationMedical Necessity AssessmentQuality ImprovementHealthcare Resource UtilizationMultitaskingTechnical Issue ResolutionEHR NavigationDirect Internet Connection

Soft Skills

Strong CommunicationCollaborationFlexibilityProblem-SolvingAttention to Detail

Tools & Technologies

Microsoft Office 365VPNEHR PortalsTeams MessagingVirtual Meeting Platforms

Certifications & Qualifications

RN LicenseAssociate Degree in NursingBSN Preferred

Industry Keywords

Utilization ManagementManaged CareHIPAA ComplianceAdult Acute CareCritical CareMed-Surg Experience

About the role

Key responsibilities & impact

Review clinical information and apply evidence-based criteria to make coverage recommendations
Collaborate with providers and interdisciplinary teams to support care coordination
Identify opportunities to improve quality, outcomes, and healthcare resource utilization
Refer members to appropriate programs and services supporting their healthcare needs
Serve as a clinical resource for internal and external stakeholders
Support the 24/7 Utilization Management team
Assess medical necessity and coordinate care
Use clinical judgment to optimize healthcare outcomes

Requirements

What you’ll need

Active, unrestricted RN license in your state of residence
2+ years of RN experience in an adult acute care or critical care setting
Associate Degree in Nursing (ADN)
Strong communication, multitasking, and computer skills
Ability to work a flexible schedule, including evenings, weekends, and holidays
Must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 25 mbs download and 3 mbs upload
WiFi and satellite internet are not permitted
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 set up and use multiple monitors and navigate multiple applications
Ability to communicate via 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 resolve common technical issues independently and contact IT for unresolved issues
Preferred: 2+ years of Med-Surg or specialty clinical experience
Preferred: Utilization Management and/or Managed Care experience
BSN preferred
Eastern Time Zone candidates preferred

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.)
Opportunity to make a direct impact on member care and outcomes
Collaborative, mission-driven healthcare environment