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 will 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.

Make a difference in patient care while leveraging your clinical expertise in a dynamic, collaborative environment.

We are seeking an experienced Registered Nurse (RN) to join our Utilization Management team. In this role, you will review clinical information, apply evidence-based criteria, and collaborate with providers to ensure members receive appropriate, high-quality healthcare services and benefits.

• Review and assess clinical information to support coverage determinations and care coordination
• Apply clinical guidelines, policies, and professional judgment to utilization management decisions
• Collaborate with providers and interdisciplinary teams to facilitate appropriate treatment and services
• Identify opportunities for care management referrals and member support programs
• Promote quality, cost-effective healthcare delivery and benefit utilization
• Provide utilization management expertise and support to internal and external stakeholders

• 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 (ADN)
• Strong communication, multitasking, and computer skills

• BSN
• Experience in Medical-Surgical nursing or a specialty clinical area
• Managed Care and/or Utilization Management experience
• Candidates located in the Central Time Zone preferred

• 24/7 operation with schedules that may include evenings, weekends, and holidays
• Remote office environment with productivity and quality performance expectations

• 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

Pay Range The typical pay range for this role is: $26.01 - $56.14

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our…