Utilization Management Nurse Consultant

CVS Health

. Coordinate, document, and communicate all aspects of the utilization/benefit management program .

Posted 10/6/2026full-timeRemote • United StatesJuniorMid-Level💰 $29 - $62 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 resource optimization and compliance with healthcare guidelines. Proficient in collaborating with multidisciplinary teams and communicating effectively with stakeholders to enhance care coordination.

Highest-signal resume keywords

RN LicensureUtilization Review ExperienceAcute Hospital Clinical ExperienceMedical Terminology KnowledgeTelephonic Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementClinical AssessmentCare CoordinationMedical Necessity EvaluationDigital Literacy SkillsProblem SolvingDecision MakingCompliance ReviewResource OptimizationDischarge Planning

Soft Skills

Interpersonal SkillsOrganizational SkillsTime Management SkillsTactful CommunicationCultural Competence

Tools & Technologies

Microsoft Office SuiteElectronic Medical Records

Certifications & Qualifications

Active RN LicensureAssociate Degree in Nursing

Industry Keywords

Healthcare ResourcesUtilization Management ProgramEvidence-Based CriteriaMultidisciplinary TeamsHealthcare Quality

About the role

Key responsibilities & impact

Coordinate, document, and communicate all aspects of the utilization/benefit management program
Drive effective utilization management by ensuring appropriate and cost-effective allocation of healthcare resources
Conduct utilization reviews and assessments using evidence-based criteria and clinical knowledge
Evaluate medical necessity and appropriateness of requested healthcare services
Collaborate with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans
Review and analyze medical records, treatment plans, and documentation for compliance with guidelines, policies, and regulations
Provide recommendations for care coordination and resource optimization
Communicate with internal and external stakeholders to facilitate care coordination and address utilization management inquiries
Provide coaching and guidance to nursing staff and healthcare professionals
Contribute to utilization management strategies, policies, and procedures
Facilitate safe and efficient discharge planning with facilities and providers
Gather clinical information and apply clinical criteria, policies, procedures, and judgment to render coverage determinations or recommendations
Identify referral opportunities and opportunities to improve healthcare quality and benefit utilization
Work Monday through Friday during standard hours in the residence time zone, with occasional varying shifts and a rotational late shift

Requirements

What you’ll need

RN with active and unrestricted state licensure in their state of residence
Associate Degree in Nursing is minimum required
2+ years of acute hospital clinical experience as an RN
Preference for medical-surgical and ICU experience
Applicants whose only acute care experience is in behavioral health are not accepted
Working knowledge of problem solving and decision making skills
Working knowledge of medical terminology
Working knowledge of digital literacy skills
Ability to deal tactfully with customers and community
Ability to handle sensitive information ethically and responsibly
Ability to consider relative costs and benefits of potential actions
Ability to function in a clinical setting with diverse cultural dynamics
Preferred: 1+ years’ experience in Utilization Review
Preferred: 1+ years’ experience in Managed Care
Strong telephonic communication skills
Preferred: 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
Experience using a computer while toggling between screens, keyboard, and speaking to customers
Ability to exercise independent and sound judgment
Strong decision-making and interpersonal skills
Ability to manage multiple priorities with effective organizational and time management skills
Ability to use a computer station and sit for extended periods of time

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