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 • California • United StatesJuniorMid-Level💰 $32 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare service coordination, clinical assessment, and utilization management, with a strong emphasis on effective communication and compliance with healthcare guidelines. Proficient in navigating multiple systems and technologies to enhance service delivery and member support.

Highest-signal resume keywords

Registered Nurse LicensureUtilization ManagementClinical AssessmentMicrosoft Office 365Effective Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical JudgmentCoverage DeterminationsHealthcare Services CoordinationEHR NavigationTechnical Issue Resolution

Soft Skills

Verbal CommunicationWritten CommunicationMultitaskingAdaptabilityPrioritization

Tools & Technologies

Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPoint

Certifications & Qualifications

Registered Nurse LicensureAssociates Degree

Industry Keywords

Healthcare ServicesBenefit ManagementHIPAA ComplianceAcute CareCritical 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 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 advise internal and external constituents on utilization and benefit management
Work in a 24/7 utilization management operation with weekend, holiday, and evening schedules
Perform work in a typical office environment with productivity and quality expectations
Inspect handwritten and computer-generated documents and PC monitor content
Sit for extended periods, talk on the telephone, type, multitask, prioritize, and adapt to a fast-paced environment

Requirements

What you’ll need

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Active, current, and unrestricted RN licensure in state of residence
Availability for weekends, holidays, and evening hours, including approximately 12 weekend days/year, 2–3 late shifts, and 1 major and 1 minor holiday/year
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously
Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals, secure computer access, manage strong passwords, and recognize suspicious emails or links
Ability to resolve common technical issues independently and contact IT for unresolved issues
Direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 50 Mbps download and 5 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 obtain required internet speeds and follow Work From Home requirements
Associates Degree required
Effective verbal and written communication skills
Computer proficiency, including navigating multiple systems and keyboarding

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.)
Remote work from home