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-timeNorth Carolina • United StatesMid-LevelSenior💰 $26 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Care Management, with a strong focus on assessing and coordinating healthcare services. Proficient in applying clinical criteria and guidelines to ensure effective coverage determinations and enhance quality of care.

Highest-signal resume keywords

Registered NurseUtilization Management ExperienceClinical JudgmentEffective Communication SkillsComputer Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationCoverage DeterminationHealthcare Services EvaluationClinical Criteria Application

Soft Skills

MultitaskingPrioritizationAdaptability

Certifications & Qualifications

Active RN Licensure

Industry Keywords

Healthcare ServicesBenefit ManagementQuality ImprovementAcute CarePost-Acute 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 to 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, or benefit programs
Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization
Consult and provide expertise to internal and external constituents in coordinating and administering utilization/benefit management
Meet productivity and quality expectations established by UMNC

Requirements

What you’ll need

Registered Nurse
Diploma RN acceptable
Associate degree/BSN preferred
3+ years of experience as a Registered Nurse
1+ years of clinical experience in an acute or post-acute setting
1+ years of Utilization Management / Care Management experience
Active, current, and unrestricted RN licensure in state of residence
May be required to obtain additional nursing licenses as business needs require
Effective verbal and written communication skills
Proficiency with computer skills, including navigating multiple systems and keyboarding
Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment
Capacity to sit for extended periods, talk on the telephone, and type on the computer
Availability to cover both Saturday and Sunday each week

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