Utilization Management Nurse Consultant

CVS Health

. Coordinate, document and communicate all aspects of the utilization/benefit management program and plan sponsors .

Posted 10/8/2026full-timeRemote • Virginia • United StatesMid-LevelSenior💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Review and Managed Care, ensuring appropriate benefit utilization and adherence to regulatory standards. Strong clinical background with a focus on patient care coordination and effective communication with healthcare providers.

Highest-signal resume keywords

Active RN LicenseUtilization Review ExperienceManaged Care ExperienceAcute Hospital Clinical ExperienceStrong Customer Service Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Record ReviewBenefit Utilization ManagementDischarge PlanningMedical Necessity AssuranceComputer Proficiency

Soft Skills

Telephonic Communication SkillsAttention to DetailProactive Problem Solving

Tools & Technologies

Microsoft OfficePowerPointExcelWord

Certifications & Qualifications

Active RN LicenseAssociate’s DegreeBSN Preferred

Industry Keywords

Utilization ManagementPatient Care CoordinationFederal and State RegulationsHealthcare Provider Collaboration

About the role

Key responsibilities & impact

Coordinate, document and communicate all aspects of the utilization/benefit management program and plan sponsors
Ensure members receive appropriate care at the appropriate time and location using designated criteria
Review written and electronic clinical records
Review services to assure medical necessity
Apply clinical expertise to assure appropriate benefit utilization
Facilitate safe and efficient discharge planning
Work closely with facilities and providers to meet complex member needs
Adhere to federal and state regulated turnaround times

Requirements

What you’ll need

Must have active current and unrestricted RN license in state of residence
Minimum of 3 years of acute hospital clinical experience as an RN
Ability to use a computer station with multiple screens, operate multiple programs simultaneously, and sit for extended periods of time
A private designated workspace free of distractions and high-speed internet
Must be willing and able to work Monday-Friday 8am-5pm EST with occasional weekend on-call and holiday rotation
Strong customer service skills including attention to customers, sensitivity to certain issues and proactive identification/resolution of issues
Experience with Microsoft Office including PowerPoint, Excel, and Word
Strong telephonic communication skills
1+ years of Utilization Review experience
1+ years of Managed Care experience
Associate’s Degree required
BSN preferred

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 in addition to base pay