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Utilization Management Nurse Consultant
CVS Health. Conduct utilization management and prior authorization reviews .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and Prior Authorization processes, ensuring compliance with clinical guidelines and benefit plans. Proficient in clinical assessment and decision-making, with strong collaboration skills to work effectively with interdisciplinary teams.
Highest-signal resume keywords
Active Registered Nurse (RN) LicenseUtilization Management ExperienceClinical Assessment SkillsMicrosoft Office ProficiencyMedical-Surgical Nursing 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 AssessmentDecision-MakingUtilization ManagementPrior AuthorizationMedical-Surgical NursingEvidence-Based Review ProcessesTroubleshooting Technical IssuesNavigating EHR PortalsHIPAA ComplianceCare Coordination
Soft Skills
Critical ThinkingCollaborationAnalytical SkillsFlexibilityCommunication
Tools & Technologies
Microsoft Office 365Google WorkspaceVPNEHR PortalsMedCompass
Certifications & Qualifications
Registered Nurse (RN) LicenseAssociate Degree in Nursing (ADN)
Industry Keywords
Medicare GuidelinesMedical Necessity CriteriaManaged CareHealth PlanPayer-Side Clinical Experience
About the role
Key responsibilities & impact- Conduct utilization management and prior authorization reviews
- Ensure members receive medically appropriate, cost-effective care based on clinical guidelines and benefit plans
- Review cases and make coverage determinations
- Apply clinical expertise and critical thinking in a non-bedside role
- Collaborate with providers and interdisciplinary teams
- Support care coordination and high-quality healthcare outcomes
- Work remotely from a designated home workspace while complying with CVS Health and HIPAA requirements
Requirements
What you’ll need- Active, unrestricted Registered Nurse (RN) license in the state of residence
- Associate Degree in Nursing (ADN) or higher
- Minimum of 3 years of clinical RN experience
- At least 1 year of Medical-Surgical (Med/Surg) nursing experience
- Strong clinical assessment, analytical, and decision-making skills
- Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel
- Ability to work Monday through Friday from 9:00 AM to 6:00 PM EST
- Flexibility to support a 24/7 Utilization Management operation, including occasional holidays, evening hours, and schedule adjustments
- Direct/hardwired internet connection with minimum 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted
- Quiet, secure, private, HIPAA-compliant designated home workspace
- Ability to use multiple monitors and navigate multiple applications
- Ability to use email, calendar invites, Teams messaging, and virtual meetings
- Experience with Microsoft Office 365 or similar Google Workspace applications
- Ability to access secure systems such as VPN and EHR portals and follow computer and password security practices
- Ability to troubleshoot common technical issues independently
- Preferred: Knowledge of Medicare guidelines, medical necessity criteria, and evidence-based review processes
- Preferred: Previous Utilization Management, Prior Authorization, or Concurrent Review experience
- Preferred: Managed care, health plan, or payer-side clinical experience
- Preferred: Experience using MedCompass or similar utilization management platforms
- Preferred: Ambulatory surgery, procedural, or perioperative nursing experience
- Preferred: Bachelor of Science in Nursing (BSN)
- Preferred: Experience collaborating with physicians, providers, and interdisciplinary healthcare teams
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, headset, etc.