Utilization Management Nurse Consultant

CVS Health

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

Posted 10/6/2026full-timeRemote • United StatesJuniorMid-Level💰 $26 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment, care coordination, and utilization management, with a strong focus on effective communication and adherence to healthcare guidelines. Proficient in navigating electronic health records and utilizing technology to enhance patient care and operational efficiency.

Highest-signal resume keywords

Registered Nurse LicensureClinical Experience in Adult Acute CareUtilization ManagementMicrosoft Office 365 ProficiencyEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationCoverage DeterminationClinical JudgmentEHR NavigationTechnical TroubleshootingMultitaskingProductivity MonitoringBenefit ManagementHealthcare Guidelines Application

Soft Skills

Effective Verbal CommunicationWritten CommunicationAdaptabilityPrioritizationOpenness to Learning

Tools & Technologies

Microsoft Office 365Google WorkspaceVPN AccessEHR PortalsTeams Messaging

Certifications & Qualifications

Active RN Licensure

Industry Keywords

Managed CareUtilization ManagementHIPAA ComplianceAdult Med SurgCritical 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, or programs
Identify opportunities to promote healthcare service quality and effective benefit utilization
Consult with and provide expertise to internal and external constituents in coordinating and administering utilization and benefit management
Work in a typical office working environment with productivity and quality expectations
Perform close inspection of handwritten and computer-generated documents and PC monitor
Sit for extended periods, talk on the telephone, and type on a computer
Multitask, prioritize, and adapt effectively to a fast-paced, changing environment

Requirements

What you’ll need

2+ years of clinical experience as a Registered Nurse in a hospital setting in adult acute care/critical care setting
Active, current and unrestricted RN licensure in state of residence
Ability to work weekends, holidays, and evening hours as part of a 24/7 operation
Proficiency with computer skills, including navigating multiple systems and keyboarding
Effective verbal and written communication skills
Associate or Bachelor of Science in Nursing; 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
Quiet, secure, private designated home virtual work location compliant with CVSHealth and HIPAA guidelines
Ability to work within the state and city where currently residing
Ability to use multiple monitors and applications simultaneously
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace tools
Ability to access secure systems such as VPN and EHR portals
Ability to follow computer and password security practices and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills
Preferred: 3+ years of clinical experience in adult med surg or specialty area
Managed Care experience preferred, especially Utilization Management
Preference for candidates residing in CST zone

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.)