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Posted: 10/21/2026Utilization Management Nurse Consultant
CVS HealthPosted 10/21/2026full-timeRemote • Virginia • United StatesMid-LevelSenior💰 $26 - $69 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting utilization reviews and clinical assessments, applying evidence-based criteria, and managing care coordination to enhance healthcare service delivery. Proficient in maintaining compliance with regulatory standards and promoting quality improvement initiatives within diverse clinical environments.
Highest-signal resume keywords
Active Registered Nurse (RN) LicenseUtilization Management ExperienceClinical Assessment SkillsHealthcare Delivery Systems KnowledgeStrong Interpersonal Skills
About the role
Key responsibilities & impact- Conduct utilization reviews and clinical assessments to evaluate medical necessity, appropriateness, and efficiency of healthcare services
- Apply evidence-based criteria and clinical expertise to benefit and utilization management decisions
- Review medical records, treatment plans, and supporting documentation for compliance
- Develop, coordinate, and support care plans with providers, multidisciplinary teams, and payers
- Prepare, audit, and manage approval and denial letters
- Promote utilization management practices through consultation, education, and collaboration
- Support care coordination to improve member outcomes and access to healthcare services
- Communicate with providers, members, and internal teams regarding utilization management decisions
- Maintain complete, accurate, and timely documentation
- Provide guidance and coaching to nursing staff and healthcare professionals
- Contribute to utilization management policies, procedures, and quality improvement initiatives
- Promote quality, effectiveness, and efficiency of healthcare services across the continuum of care
Requirements
What you’ll need- Active Registered Nurse (RN) license
- 3-5 years of relevant clinical, case management, utilization management, or healthcare experience
- Knowledge of medical terminology and healthcare delivery systems
- Strong problem-solving and critical-thinking skills
- Effective decision-making abilities with demonstrated clinical judgment
- Proficiency with technology and digital tools used in healthcare environments
- Ability to analyze costs and benefits of alternative approaches and recommend appropriate solutions
- Strong interpersonal and communication skills
- Ability to maintain confidentiality and handle sensitive information ethically and responsibly
- Ability to work effectively within diverse clinical and cultural environments
- Must be available to work Thursday-Sunday, 9:00 AM to 8:00 PM Eastern Time
- Experience in utilization management, care management, managed care, or health plan operations preferred
- Knowledge of regulatory, accreditation, and quality standards related to utilization management preferred
- Experience reviewing medical necessity criteria and healthcare benefits preferred
- Bachelor's degree in Nursing, Healthcare Administration, or a related healthcare field preferred
- Equivalent specialized training, certification, or relevant professional experience may be considered in lieu of a degree
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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewClinical AssessmentMedical Necessity Criteria ReviewCare CoordinationCost-Benefit AnalysisDocumentation ManagementQuality Improvement InitiativesEvidence-Based Criteria ApplicationDecision-Making AbilitiesHealthcare Compliance
Soft Skills
Problem-Solving SkillsCritical-Thinking SkillsEffective CommunicationInterpersonal SkillsEthical Handling of Sensitive Information
Tools & Technologies
Digital Tools in HealthcareHealthcare Management Software
Industry Keywords
Healthcare ServicesManaged CareCare ManagementRegulatory StandardsAccreditation StandardsQuality Standards