Utilization Management Nurse Consultant

CVS Health

. Assess, plan, implement, coordinate, monitor, and evaluate healthcare service and benefit options .

Posted 10/6/2026full-timeRemote • United StatesMid-LevelSenior💰 $32 - $69 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in healthcare service assessment, planning, and implementation, with a strong focus on clinical criteria application and effective communication with providers. Proficient in utilizing IT platforms for benefit management and maintaining compliance with HIPAA guidelines.

Highest-signal resume keywords

Acute Care RN ExperienceActive RN LicensureUtilization Management FunctionsMicrosoft Office ApplicationsClinical Criteria Application

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare Service AssessmentClinical JudgmentCoverage DeterminationsBenefit UtilizationUtilization ManagementInternet Speed ComplianceTechnical TroubleshootingEHR Portals AccessMultiple Monitor NavigationVPN Login

Soft Skills

CommunicationCoordinationConsultationProblem-SolvingInterpersonal Skills

Tools & Technologies

Microsoft Office 365Google WorkspaceIT PlatformsSecure SystemsVPN

Certifications & Qualifications

RN LicensureAssociates Degree in Nursing

Industry Keywords

Healthcare Service QualityBenefit ManagementHIPAA ComplianceClinical GuidelinesReferral Opportunities

About the role

Key responsibilities & impact

Assess, plan, implement, coordinate, monitor, and evaluate healthcare service and benefit options
Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment
Render coverage determinations or recommendations across the continuum of care
Communicate with providers and other parties to facilitate care and treatment
Identify members for referral opportunities to other products, services, and programs
Identify opportunities to promote healthcare service quality and effective benefit utilization
Consult with and provide expertise to internal and external constituents
Coordinate and administer utilization and benefit management functions
Work a permanent Monday-Friday schedule from 8 a.m. to 5 p.m. EST
Support a 24/7 utilization management operation, which may include weekends, holidays, and evening hours

Requirements

What you’ll need

3+ years of experience as an acute care RN
Active and unrestricted RN licensure in state of residence
Able to work in multiple IT platforms/systems
1+ years of experience with Microsoft Office Applications (Outlook, Teams, Excel)
Associates Degree in Nursing required
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
WiFi and satellite internet are not permitted
Quiet, secure, private designated home work location 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 information security
Ability to troubleshoot common technical issues
Must be willing to obtain required internet speeds and follow Work From Home requirements

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program
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, and headset