Utilization Management Nurse Consultant

CVS Health

. Review clinical cases and make coverage determinations using evidence-based guidelines .

Posted 10/26/2026full-timeRemote • United StatesMid-LevelSenior💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates strong clinical assessment and decision-making skills while effectively collaborating with providers and care teams to enhance treatment outcomes. Proficient in utilizing Microsoft Office applications and navigating secure systems to support clinical operations.

Highest-signal resume keywords

Active RN License3+ Years RN ExperienceClinical Assessment SkillsMicrosoft Office ProficiencyMed/Surg Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical JudgmentUtilization ManagementBenefit ManagementCare Quality ImprovementEHR NavigationTechnical TroubleshootingComputer Security PracticesEvidence-Based Guidelines

Soft Skills

CollaborationCommunicationDecision-MakingOpenness to Learning

Tools & Technologies

Microsoft Office 365Google WorkspaceVPNEHR Portals

Certifications & Qualifications

RN LicenseAssociate Degree in Nursing

Industry Keywords

HIPAA ComplianceClinical ResourceCare CoordinationMember Outcomes24/7 Operations

About the role

Key responsibilities & impact

Review clinical cases and make coverage determinations using evidence-based guidelines
Collaborate with providers and care teams to coordinate appropriate treatment
Apply clinical judgment to utilization and benefit management decisions
Identify opportunities to improve care quality and member outcomes
Serve as a clinical resource across internal and external stakeholders
Work a weekday schedule, with potential holidays and evening hours due to 24/7 operations

Requirements

What you’ll need

Active, unrestricted RN license in the state of residence
3+ years of RN experience, including 1+ year in Med/Surg
Strong clinical assessment and decision-making skills
Experience with Microsoft Office (Outlook, Teams, Excel)
Ability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone; schedules may include holidays and evening hours
Associate Degree in Nursing
Must work within the state and city where currently living
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
Quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines
Must provide workspace furniture, such as a desk or standing desk
Comfortable using multiple monitors and navigating multiple applications
Ability to communicate via 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 follow computer security practices, manage strong passwords, and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills as the workplace evolves

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
Supportive, team-driven work environment