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Utilization Management Nurse Consultant
CVS Health. Review clinical cases and make coverage determinations using evidence-based guidelines .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical assessment and decision-making skills while effectively coordinating care and improving healthcare quality. Utilizes an active RN license and extensive experience in Med/Surg to support utilization management and member outcomes.
Highest-signal resume keywords
Active RN License3+ Years RN ExperienceUtilization Management ExperienceClinical Assessment SkillsMicrosoft Office Proficiency
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 JudgmentCare CoordinationEvidence-Based GuidelinesDecision-Making SkillsTroubleshooting Technical IssuesAmbulatory Surgery ExperienceMed/Surg ExperiencePrior Authorization ExperienceFamiliarity with MedCompassInternet Speed Compliance
Soft Skills
CollaborationCommunicationProblem-Solving
Tools & Technologies
Microsoft Office 365Google WorkspaceVPNEHR Portals
Certifications & Qualifications
Associate Degree in NursingBSN Preferred
Industry Keywords
Managed CareUtilization ManagementHealthcare QualityHIPAA Compliance
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 support utilization and benefit management decisions
- Identify opportunities to improve care quality and member outcomes
- Serve as a clinical resource across internal and external stakeholders
- Use clinical expertise to support members receiving the right care at the right time
- Work in a remote, non-bedside utilization management role
- Coordinate care and support healthcare quality
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
- 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 work within the state and city where currently living
- Ability to use multiple monitors and navigate multiple applications
- Experience with Microsoft Office 365 applications or similar Google Workspace tools
- Ability to log in to secure systems such as VPN and EHR portals
- Ability to maintain computer and password security and recognize suspicious emails or links
- Ability to troubleshoot common technical issues independently
- Must obtain required internet speeds and adhere to Work From Home requirements if hired
- Utilization Management or Prior Authorization experience preferred
- Managed care background preferred
- Familiarity with MedCompass preferred
- Ambulatory surgery experience preferred
- BSN preferred
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