Utilization Management Nurse Consultant

Registered Nurse (RN) – Utilization Management

Make a difference in healthcare from a clinical review and care coordination perspective.

We are seeking an experienced Registered Nurse (RN) to join our Utilization Management team. In this role, you will leverage your clinical expertise to review cases, evaluate medical necessity, coordinate care, and support members in accessing appropriate healthcare services and benefits.

What You'll Do

• Review clinical information and apply evidence-based guidelines to make coverage recommendations and determinations
• Collaborate with providers and healthcare teams to facilitate appropriate care and treatment
• Identify opportunities for care management, quality improvement, and member support programs
• Provide clinical expertise to internal and external partners on utilization and benefit management activities
• Navigate multiple systems while managing a fast-paced, highly collaborative workload

Required Qualifications

• Active, unrestricted RN license in your state of residence
• Minimum 2 years of RN experience in an adult acute care or critical care setting
• Associate Degree in Nursing required
• Strong communication, organizational, and multitasking skills
• Ability to work schedules that may include evenings, weekends, and holidays as part of a 24/7 operation

Preferred Qualifications

• 2+ years of Med Surg or other specialty clinical experience
• Utilization Management and/or Managed Care experience
• BSN preferred
• Eastern Time Zone residency preferred

Why Join Us?

• Apply your clinical expertise in a non-bedside setting
• Be part of a team focused on quality care, member outcomes, and healthcare excellence
• Collaborate with experienced healthcare professionals in a dynamic environment

If you're a clinically strong RN looking to expand your impact beyond direct patient care, we'd love to hear from you.

Work from Home Requirements:

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:

• Device & System Navigation:
  Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools:
  Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling:
  Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security:
  Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support:
  Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth:
  Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

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…