Utilization Management Nurse Consultant

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.

• Review and assess clinical information for Medicare precertification (joint procedures)
• Apply evidence-based criteria and clinical judgment to make coverage determinations
• Collaborate with providers and care teams to coordinate appropriate treatment plans
• Identify opportunities to improve care quality and optimize healthcare utilization
• Support care integration by connecting members to additional programs and services
• Serve as a clinical resource to internal and external partners

• Active, unrestricted RN license in the state of residence
• 3+ years of RN experience
• 1+ year of Med/Surg experience
• Proficiency in Microsoft Office (Outlook, Teams, Excel)
• Associates degree in nursing

Nice to Have

• Utilization Management or Prior Authorization experience
• Managed care and/or Medicare experience
• Med Compass or similar system experience
• Ambulatory surgery background
• BSN

• Consistent weekday schedule (with some flexibility for a 24/7 operation)
• Opportunity to use your clinical expertise in a non-bedside role
• Collaborative, mission-driven team focused on quality care
• Work from Home

• 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.

• 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

Pa…