Utilization Management Nurse Consultant

CVS Health

. Review clinical documentation and apply evidence-based criteria, policies, and clinical judgment to support coverage determinations .

Posted 9/17/2026full-timeRemote • United StatesJuniorMid-Level💰 $26 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment, care coordination, and utilization management, with a strong focus on improving healthcare quality and outcomes. Proficient in navigating technology-driven environments and collaborating with interdisciplinary teams to support effective treatment plans.

Highest-signal resume keywords

Active RN LicenseClinical Assessment SkillsUtilization Management ExperienceMicrosoft Office 365 ProficiencyCritical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewEvidence-Based Criteria ApplicationHealthcare Services EvaluationCare CoordinationAdult Acute Care ExperienceCritical Care Nursing ExperienceMed-Surg Nursing ExperienceTroubleshooting Technical IssuesVPN AccessEHR Portal Navigation

Soft Skills

Communication SkillsCritical ThinkingTime ManagementCollaborationAdaptability

Tools & Technologies

Computer-Based Utilization ManagementEmail CommunicationCalendar ManagementTeams MessagingVirtual Meeting Platforms

Certifications & Qualifications

Associate Degree in NursingBSN Preferred

Industry Keywords

Managed CareHealthcare Quality ImprovementHIPAA ComplianceNorth Central Time Zone ResidencePositive Health Outcomes

About the role

Key responsibilities & impact

Review clinical documentation and apply evidence-based criteria, policies, and clinical judgment to support coverage determinations
Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care
Collaborate with providers and care teams to facilitate appropriate treatment plans and care coordination
Identify opportunities to improve healthcare quality, effectiveness, and benefit utilization
Connect members to programs and resources supporting positive health outcomes
Serve as a clinical resource and consultant to internal and external stakeholders
Work in a computer-based 24/7 utilization management operation
Collaborate frequently with providers, members, and interdisciplinary teams

Requirements

What you’ll need

Active, unrestricted RN license in your state of residence
2+ years of adult acute care and/or critical care nursing experience
Strong clinical assessment, critical thinking, and communication skills
Ability to manage multiple priorities in a fast-paced, technology-driven environment
Proficiency navigating multiple computer systems
Associate Degree in Nursing required
2+ years of Med-Surg or specialty nursing experience preferred
Managed Care or Utilization Management experience preferred
Residence in the North Central Time Zone preferred
BSN preferred
Ability to work evenings, weekends, and holidays as schedules may require
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
Microsoft Office 365 applications or similar Google Workspace experience
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Ability to access secure systems such as VPN and EHR portals
Ability to manage strong passwords and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills as the workplace evolves

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to base pay
Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
Remote work from home
Company-provided equipment including keyboard, monitor, computer, and headset