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Posted: 10/21/2026Utilization Management Nurse Consultant – Medical Review
CVS HealthPosted 10/21/2026full-timeRemote • Missouri • United StatesMid-LevelSenior💰 $26 - $56 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review processes, applying evidence-based criteria and guidelines to make independent medical determinations. Proficient in training and mentoring nursing staff while collaborating effectively with healthcare providers to ensure timely and necessary patient care.
Highest-signal resume keywords
Active RN LicenseClinical ExperienceUtilization Review ManagementMCG Milliman ExperienceClinical Judgment
About the role
Key responsibilities & impact- Implement, coordinate, monitor and evaluate medical review cases using clinical experience and skills
- Apply clinical criteria, guidelines, plan language and policy specifics to render medical determinations to clients
- Use critical thinking, evidence-based clinical criteria and clinical practice guidelines
- Authorize procedures/services or initiate Medical Director referrals as needed
- Assist management with training new nurse reviewers, business partners or vendors through initial and ongoing mentoring and feedback
- Cross-train to perform reviews of multiple case types
- Recommend, test and implement process, audit and technology improvements
- Work independently to meet quality and metric expectations
- Collaborate with providers to help members receive timely, medically necessary care
Requirements
What you’ll need- Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges
- Ability to obtain licensure in non-compact states as needed
- Minimum 3 years of clinical experience
- 5 years demonstrated to make thorough independent decisions using clinical judgement
- 5 years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems
- 1+ year of Utilization Review Management and/or Medical Management experience
- Commitment to attend a mandatory 3-week training, Monday–Friday, 8:30am–5:00pm EST, with 100% participation
- Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity preferred
- MCG Milliman, CPB or other criteria guideline application experience preferred
- Associate's degree in nursing (RN) required
- BSN preferred
- Dedicated workspace free of interruptions
- Dependents must have separate care arrangements during work hours
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
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 ReviewEvidence-Based Criteria ApplicationMedical DeterminationClinical Documentation SystemsIndependent Decision MakingPlan Language InterpretationPolicy ApplicationProcess ImprovementAudit ImplementationCritical Thinking
Soft Skills
MentoringCollaborationCommunicationTrainingProblem Solving
Tools & Technologies
Clinical Documentation SystemsComputerPhone
Certifications & Qualifications
RN LicenseAssociate's Degree in NursingBSN Preferred
Industry Keywords
Utilization ReviewMedical ManagementClinical Practice GuidelinesHealthcare ProvidersMedical Necessity