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Utilization Management Nurse Consultant
CVS Health. Review clinical documentation and apply medical necessity criteria, policies, and clinical guidelines to make coverage determinations and recommendations .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical assessment, documentation, and critical thinking to support evidence-based care and effective resource utilization. Proficient in utilization management processes, care coordination, and promoting quality improvement initiatives within healthcare settings.
Highest-signal resume keywords
Registered Nurse (RN) LicenseInpatient Clinical Nursing ExperienceUtilization Management (UM) ExperienceCritical Thinking SkillsCare Coordination 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 AssessmentDocumentationMedical Necessity GuidelinesUtilization Review CriteriaDischarge PlanningCrisis InterventionCare Management ProgramsEvidence-Based CareResource Utilization
Soft Skills
Communication SkillsCollaborationCritical Thinking
Certifications & Qualifications
Associate Degree in Nursing (ADN)Active, Unrestricted RN License
Industry Keywords
Utilization ManagementManaged CareHealthcare OutcomesQuality Improvement InitiativesCare Transitions
About the role
Key responsibilities & impact- Review clinical documentation and apply medical necessity criteria, policies, and clinical guidelines to make coverage determinations and recommendations
- Coordinate and communicate utilization and benefit management activities across the continuum of care
- Collaborate with providers, healthcare teams, and internal stakeholders on treatment plans, discharge planning, and care transitions
- Apply critical thinking and clinical judgment to support evidence-based care and appropriate resource utilization
- Identify members who may benefit from care management programs and facilitate referrals
- Support urgent and emergent member needs, including triage and crisis intervention when necessary
- Serve as a clinical resource and consultant for internal and external partners regarding utilization management processes and decisions
- Promote quality improvement initiatives and identify opportunities to enhance healthcare outcomes and benefit utilization
Requirements
What you’ll need- Active, unrestricted Registered Nurse (RN) license in the state of Florida
- Minimum of 3 years of recent inpatient clinical nursing experience
- Ability and willingness to obtain additional state nursing licenses as needed (company-sponsored)
- Must permanently reside in Florida
- Strong clinical assessment, documentation, communication, and critical-thinking skills
- Associate Degree in Nursing (ADN) required
- Previous Utilization Management (UM) experience preferred
- Managed Care experience preferred
- Discharge planning and care coordination experience preferred
- Experience applying medical necessity guidelines and utilization review criteria preferred
- Schedules may include evenings, weekends, and holidays
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, based on eligibility