Utilization Management Nurse Consultant

CVS Health

. Assess, plan, implement, coordinate, monitor, and evaluate healthcare service and benefit options for members .

Posted 11/11/2026full-timeRemote • United StatesJuniorMid-Level💰 $32 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare service assessment, clinical criteria application, and effective communication with providers. Proficient in utilizing technology for documentation and remote work while adhering to compliance standards.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceClinical JudgmentMicrosoft Office 365 ProficiencyManaged Care Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCoverage DeterminationBenefit ManagementDocument InspectionMultitaskingEHR NavigationComputer Security PracticesTechnical Issue ResolutionInternet Speed ComplianceHealthcare Quality Promotion

Soft Skills

Effective CommunicationOpenness to LearningCollaborationProblem-Solving

Tools & Technologies

Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPointVPNEHR Portals

Certifications & Qualifications

Active RN LicensureAssociate Degree

Industry Keywords

Healthcare ServicesBenefit UtilizationClinical GuidelinesHIPAA ComplianceManaged Care

About the role

Key responsibilities & impact

Assess, plan, implement, coordinate, monitor, and evaluate healthcare service and benefit options 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, and programs
Identify opportunities to promote healthcare service quality and effective benefit utilization
Consult with and provide expertise to internal and external constituents regarding utilization and benefit management
Work in a 24/7 utilization management operation with weekend, holiday, and evening schedules
Perform computer-based document inspection, telephone communication, typing, multitasking, and navigation of multiple systems

Requirements

What you’ll need

2+ years of experience as a Registered Nurse in an adult acute care/critical care setting
Active, current, and unrestricted RN licensure in the state of residence
Availability for weekends, holidays, and evening hours, including approximately 12 weekend days/year, 2–3 late shifts, and 1 major and 1 minor holiday/year
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously
Ability to communicate through email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals
Ability to follow computer security practices, including locking screens, managing strong passwords, and recognizing suspicious emails or links
Ability to resolve common technical issues independently and contact IT for unresolved issues
Openness to learning new skills as the workplace evolves
Direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 50 Mbps download and 5 Mbps upload; WiFi and satellite internet are not permitted
Quiet, secure, private, and designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Must provide workspace furniture, such as a desk or standing desk
Must obtain required internet speeds and comply with Work From Home requirements if hired
Associate degree required
Managed Care experience preferred, especially Utilization Management
2+ years of clinical experience in med surg or a specialty area preferred
Preference for candidates residing in PST zones

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, including keyboard, monitor, computer, and headset