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Utilization Management Nurse Consultant
CVS Health. Utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options for appropriate healthcare services and benefits .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical assessment, care coordination, and utilization management, with a strong focus on healthcare service quality and effective benefit utilization. Proficient in applying clinical criteria and guidelines to make informed coverage determinations.
Highest-signal resume keywords
Registered Nurse LicensureUtilization Management ExperienceMed/Surg ExperienceMicrosoft Office ProficiencyPrior Authorization Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentCare CoordinationCoverage DeterminationClinical JudgmentBenefit Management
Soft Skills
CommunicationCollaboration
Tools & Technologies
Microsoft OutlookMicrosoft TeamsMicrosoft ExcelMedCompass
Certifications & Qualifications
Active RN LicensureAssociate DegreeBSN Preferred
Industry Keywords
Managed CareAmbulatory SurgeryHealthcare ServicesClinical GuidelinesUtilization Management
About the role
Key responsibilities & impact- Utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options for appropriate healthcare services and benefits
- 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, and 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
Requirements
What you’ll need- 3+ years of experience as a Registered Nurse
- Active, current and unrestricted RN licensure in state of residence
- 1+ years of Med/Surg experience
- 1+ years of experience with Microsoft Office applications, including Outlook, Teams, and Excel
- Willingness and ability to work Monday through Friday, 9:00am to 5:30pm Eastern or Central Time, with occasional holiday rotation
- Availability for holidays and evening hours because Utilization Management is a 24/7 operation
- Prior Authorization or Utilization Management experience preferred
- Managed care experience preferred
- Experience using MedCompass preferred
- Ambulatory surgery experience preferred
- Associate degree required
- BSN preferred
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- CVS Health bonus, commission or short-term incentive program eligibility