Utilization Management Nurse Consultant

CVS Health

. Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services and benefits for members .

Posted 10/14/2026full-timeRemote • United StatesJuniorMid-Level💰 $32 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and clinical assessment, with a strong focus on effective communication and coordination of healthcare services. Proficient in managing care quality and compliance with HIPAA guidelines while utilizing technology for efficient operations.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceClinical Assessment SkillsMicrosoft Office 365 ProficiencyEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationUtilization ManagementHealthcare Services EvaluationKeyboarding ProficiencyTroubleshooting Technical IssuesEHR Portal UsageClinical Criteria ApplicationProductivity MonitoringQuality Assurance

Soft Skills

Effective Verbal CommunicationEffective Written CommunicationMultitasking AbilityAttention to DetailProblem-Solving Skills

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR PortalsSecure Systems

Certifications & Qualifications

Active RN LicensureAssociate DegreeBSN Preferred

Industry Keywords

Managed CareHIPAA ComplianceAdult Acute CareCritical CareMed Surg

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 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 internal and external constituents on utilization and benefit management
Work within a 24/7 operation including weekends, holidays and evening hours
Meet productivity and quality expectations in a typical office working environment
Perform close inspection of handwritten and computer-generated documents and PC monitors
Sit for extended periods, talk on the telephone, type and multitask

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
2+ years of clinical experience in med surg or specialty area
Managed Care experience preferred, especially Utilization Management
Preference for candidates residing in PST zones
Associate Degree required
BSN preferred
Direct/hardwired internet connection to a 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 and private designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently residing
Proficiency with computer skills, multiple systems and keyboarding
Effective verbal and written communication skills
Ability to work weekends, holidays and evening hours
Experience with Microsoft Office 365 or similar Google Workspace applications
Ability to use secure systems such as VPN and EHR portals
Ability to troubleshoot common technical issues and follow security practices

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