Utilization Management Nurse Consultant

About the Role

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Join a dynamic healthcare team where your clinical expertise helps ensure members receive the right care at the right time. We are seeking an experienced Registered Nurse (RN) to support our Utilization Management team. In this role, you will review clinical information, apply evidence-based criteria and clinical judgment, communicate with providers, and help coordinate effective, high-quality healthcare services for members.

• Review and assess clinical information to support utilization and coverage determinations
• Collaborate with providers, care teams, and internal partners to facilitate appropriate treatment and care plans
• Identify opportunities for care management referrals and member support programs
• Promote quality, cost-effective healthcare outcomes
• Serve as a clinical resource for utilization and benefit management activities

• Active, unrestricted RN license in state of residence
• 2+ years of RN experience in adult acute care or critical care settings
• Strong clinical assessment, communication, and computer skills
• Ability to thrive in a fast-paced, highly collaborative environment
• Associates Degree in Nursing

• 2+ years of Med-Surg or specialty clinical experience
• Managed Care and/or Utilization Management experience
• Candidates residing in Eastern time zones preferred
• BSN

Utilization Management operates 24/7 Monday – Friday 8:00 am to 5:00 pm in the time zone where you live. Schedules include evenings (until 7pm), weekends, and holidays (based on business needs). Remote/office-based environment with extensive computer and telephone use Sedentary role requiring effective multitasking and navigation of multiple systems

• 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

• 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…