Utilization Management Nurse Consultant

Lifelancer

. Review services for medical necessity and appropriate benefit use .

Posted 9/30/2026full-timeRemote • 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, ensuring appropriate care delivery while adhering to state and federal regulations. Proficient in coordinating healthcare services and collaborating with diverse teams to support members with complex needs.

Highest-signal resume keywords

Active RN LicenseUtilization Review ExperienceManaged Care ExperienceClinical Assessment SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentDecision-MakingDischarge PlanningCare CoordinationCoverage DeterminationDocumentationMultitaskingHealthcare Services EvaluationBenefit ManagementJudgment Application

Soft Skills

Organizational SkillsEffective CommunicationCollaborationIndependent WorkSound Judgment

Certifications & Qualifications

Associate Degree in Nursing (ADN)Bachelor of Science in Nursing (BSN)

Industry Keywords

Medical NecessityBenefit UtilizationAcute Hospital ExperienceTelephonic CommunicationComplex NeedsQuality Care DeliveryState and Federal RequirementsHealthcare GuidelinesClinical CriteriaBehavioral Health

About the role

Key responsibilities & impact

Review services for medical necessity and appropriate benefit use
Facilitate efficient discharge planning
Collaborate with providers and facilities to support members with complex needs
Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits
Collect and evaluate clinical information
Apply clinical criteria, guidelines, policies, and judgment to make coverage determinations
Communicate with providers and external partners to coordinate care and treatment plans
Identify opportunities for referrals to additional programs, services, or care solutions
Promote quality care delivery and effective benefit utilization
Serve as a resource to internal and external stakeholders regarding utilization management processes and clinical considerations
Coordinate, document, and communicate all aspects of the utilization and benefit management process
Ensure members receive appropriate care while meeting state and federal requirements and turnaround times

Requirements

What you’ll need

Active, unrestricted RN license
2+ years of acute hospital clinical experience
Strong preference for medical-surgical, ICU, behavioral health or another specialty area
Strong clinical assessment and decision-making abilities
Excellent organizational skills and ability to manage multiple priorities
Ability to work independently and communicate effectively via phone
Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls
1+ year of Utilization Review experience preferred
1+ year of Managed Care experience preferred
Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) preferred
Strong telephonic communication skills preferred
Demonstrated ability to exercise sound judgment and collaborate with diverse teams
Associate Degree in Nursing (ADN) required
Bachelor of Science in Nursing (BSN) preferred
Must work in the EST or CST time zones
Ability to work Monday-Friday 8:00 AM-5:00 PM, with a 10:00 AM-7:00 PM shift required once a month
Includes 12 weekends per year and rotating holidays (one minor and one major per year)

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
Resources supporting physical, emotional, and financial well-being
Full-time comprehensive benefits package