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 • 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 assess healthcare services. Proficient in Microsoft Office applications and capable of navigating secure systems while maintaining compliance with HIPAA regulations.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceMed/Surg ExperienceMicrosoft Office ProficiencyAmbulatory Surgery Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCoverage DeterminationClinical Criteria ApplicationHealthcare Service CoordinationUtilization ManagementPrior AuthorizationEHR NavigationTechnical TroubleshootingDigital CommunicationMultiple Monitor Usage

Soft Skills

Effective CommunicationCollaborationAdaptabilityProblem-SolvingAttention to Detail

Tools & Technologies

Microsoft Office 365Google WorkspaceMedCompassVPNEHR Portals

Certifications & Qualifications

Active RN Licensure

Industry Keywords

Managed CareHealthcare ServicesClinical GuidelinesHIPAA ComplianceHealthcare Quality Improvement

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, effectiveness and benefit utilization
Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
Work remotely from the confirmed residential city and state

Requirements

What you’ll need

3+ years of experience as a Registered Nurse
Active, current, unrestricted RN licensure in state of residence
1+ years of Med/Surg experience
1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
Associate degree required
Prior Authorization or Utilization Management experience preferred
Managed care experience preferred
Experience using MedCompass preferred
Ambulatory surgery experience preferred
Must work Monday through Friday during specified eastern or central time hours, with occasional holiday rotation
Willingness and ability to work evening hours and holidays as part of a 24/7 Utilization Management operation
Direct/hardwired internet connection within 7 feet of computer/router, with minimum 25 Mbps download and 3 Mbps upload
Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
Ability to use multiple monitors and navigate multiple applications
Ability to use digital communication channels and virtual meeting tools
Experience with Microsoft Office 365 or similar Google Workspace applications
Ability to access secure systems such as VPN and EHR portals and follow security practices
Ability to troubleshoot common technical issues independently
Openness to learning new skills as the workplace evolves

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