Utilization Management Nurse Consultant

CVS Health

. Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services and benefits for members .

Posted 11/3/2026full-timeRemote • Pennsylvania • United StatesJuniorMid-Level💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and clinical assessment, with a strong focus on effective communication and coordination of healthcare services. Proficient in navigating multiple applications and maintaining compliance with healthcare regulations.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceClinical Assessment SkillsMicrosoft Office 365 ProficiencyEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical JudgmentCoverage DeterminationsHealthcare Service CoordinationClinical Criteria ApplicationMed Surg ExperienceCritical Care ExperienceTechnical Issue ResolutionEHR NavigationVPN AccessPassword Management

Soft Skills

Verbal CommunicationWritten CommunicationInterpersonal SkillsOrganizational SkillsProblem-Solving Skills

Tools & Technologies

Microsoft TeamsMicrosoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPointGoogle WorkspaceSecure Systems AccessVirtual Meeting Platforms

Certifications & Qualifications

Active RN LicensureAssociates Degree

Industry Keywords

Managed CareHealthcare ServicesBenefit ManagementHIPAA ComplianceClinical Guidelines

About the role

Key responsibilities & impact

Assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services and benefits for members
Gather clinical information and apply clinical criteria, guidelines, policies, procedures and clinical judgment to render coverage determinations or recommendations
Communicate with providers and other parties to facilitate care and treatment
Identify members for referral opportunities involving 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 in coordinating and administering utilization and benefit management
Work a typical Monday-Friday 8:00 AM-5:00 PM EST schedule, with possible weekends, holidays and evening hours

Requirements

What you’ll need

2+ years of experience as a Registered Nurse in adult acute care/critical care setting
Active, current and unrestricted RN licensure in state of residence
Associates Degree required
2+ years of clinical experience in med surg or specialty area
Managed Care experience preferred, especially Utilization Management
Preference for those residing in EST zones
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously
Ability to communicate via email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals
Ability to manage strong passwords and recognize suspicious emails or links
Ability to resolve common technical issues independently
Direct/hardwired internet connection to a modem/router within 7 feet of the computer
Minimum internet speed of 50 Mbps download and 5 Mbps upload
Quiet, secure and private designated home virtual work location compliant with CVS Health and HIPAA guidelines
Ability to work within the state and city where currently residing
Ability to provide workspace furniture, such as a desk or standing desk
Ability to work weekends, holidays, and evening hours in a 24/7 operation
Effective verbal and written communication skills
Computer proficiency, including navigating multiple systems and keyboarding

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 (keyboard, monitor, computer, headset, etc.)