Utilization Management Nurse Consultant; live in Pacific Time Zone

Utilization Management Nurse Consultant (Must live in Pacific Time Zone.)

Join to apply for the Utilization Management Nurse Consultant (Must live in Pacific Time Zone.) role at CVS Health

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels, and more than 300,000 purpose-driven colleagues – caring for people where, when, and how they choose in a way that is uniquely more connected, more convenient and more compassionate.

And we do it all with heart, each and every day.

This Utilization Management (UM) Nurse Consultant role is fully remote but must reside in PST zone.

• Monday through Friday between 8am-5pm PST.
• Weekend shift requirement (Saturday and Sunday) per the needs of the team.
• Holiday rotation per the need of the department (typically 1 holiday per year).

There is no travel expected with this position.

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning, and works closely with facilities and providers to meet the complex needs of the member.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• Must reside in PST zone.
• RN with active and unrestricted state licensure in state of residence.
• 3+ years of clinical experience as an RN, preferably in the following areas:
  Med/Surg, Telemetry, ICU, NICU, Long term care, cardiology.

• 1+ years’ experience in either Precertification or Utilization Review.
• 1+ years’ experience Managed Care.
• Strong telephonic communication skills.
• 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook).
• Experience with computers toggling between screens while using a keyboard and speaking to customers.
• Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills.
• Ability to manage multiple priorities, effective organizational and time management skills required.
• Ability to use a computer station and sit for extended periods of time.

• Associates Degree in Nursing required, BSN preferred.

40

Full time

$29.10 - $68.55

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues, including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We anticipate the application window for this opening will close on: 01/03/2026.