Utilization Management Nurse Consultant

CVS Health

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

Posted 10/5/2026full-timeRemote • United StatesMid-LevelSenior💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment, care coordination, and utilization management within a healthcare setting, with a strong emphasis on effective communication and compliance with healthcare guidelines.

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 DeterminationsClinical Criteria ApplicationMultitaskingComputer ProficiencyEHR NavigationTechnical Issue ResolutionDocument InspectionBenefit Management

Soft Skills

Effective Verbal CommunicationWritten CommunicationAdaptabilityPrioritizationTeam Collaboration

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR PortalsTeams Messaging

Certifications & Qualifications

Active RN LicensureBSN Preferred

Industry Keywords

Managed CareHealthcare ServicesHIPAA 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 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 and programs
Identify opportunities to promote healthcare service quality and benefit utilization
Consult 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
Participate in a 24/7 operation with schedules including weekends, holidays and evening hours

Requirements

What you’ll need

3+ years of clinical experience as a Registered Nurse in a hospital setting in an adult acute care/critical care setting
Active, current and unrestricted RN licensure in the state of residence
3+ years of clinical experience in adult med surg or a specialty area
Managed Care experience preferred, especially Utilization Management
Preference for candidates residing in the EST zone
Associate or Bachelor of Science in Nursing (BSN preferred)
Direct/hardwired internet connection to a modem/router within 7 feet of the 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 virtual work location compliant with CVSHealth and HIPAA guidelines
Ability to work weekends, holidays and evening hours as part of a 24/7 operation
Ability to perform close inspection of handwritten and computer-generated documents and a PC monitor
Ability to sit for extended periods, talk on the telephone and type on a computer
Ability to multitask, prioritize and adapt to a fast-paced changing environment
Computer proficiency, including navigating multiple systems and keyboarding
Effective verbal and written communication skills
Ability to set up and use multiple monitors and navigate multiple applications simultaneously
Ability to use email, calendar invites, Teams messaging and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals
Ability to manage strong passwords and recognize suspicious emails or links
Ability to resolve common technical issues independently
Openness to learning new skills as the workplace environment evolves
Must work within the state and city where currently living

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.)