Utilization Management Nurse Consultant
About The Position
The Utilization Management Nurse supports the coordination and management of healthcare services by reviewing clinical information, determining medical necessity, facilitating appropriate resource utilization, and ensuring compliance with regulatory and accreditation requirements. The role promotes quality, cost-effective care through accurate documentation and collaboration with internal and external stakeholders to optimize member outcomes. This full-time position is scheduled Thursday through Sunday, 9:00 AM to 8:00 PM Eastern Time, for 40 anticipated weekly hours. The typical pay range is $26.01–$68.55 per hour or equivalent base annual full-time salary, depending on factors such as experience, education, and geography. The position may also be eligible for a CVS Health bonus, commission, or short-term incentive program. A comprehensive benefits package is available based on eligibility.
Requirements
- Active Registered Nurse (RN) license.
- 3–5 years of relevant clinical, case management, utilization management, or healthcare experience.
- Knowledge of medical terminology and healthcare delivery systems.
- Strong problem-solving and critical-thinking skills.
- Effective decision-making abilities and demonstrated clinical judgment.
- Proficiency with technology and digital tools used in healthcare environments.
- Ability to analyze the costs and benefits of alternative approaches and recommend appropriate solutions.
- Strong interpersonal and communication skills, including the ability to interact professionally with providers, members, and community partners.
- Ability to maintain confidentiality and handle sensitive information ethically and responsibly.
- Ability to work effectively within diverse clinical and cultural environments.
- Availability to work Thursday through Sunday, 9:00 AM to 8:00 PM Eastern Time.
Nice To Haves
- Experience in utilization management, care management, managed care, or health plan operations.
- Knowledge of regulatory, accreditation, and quality standards related to utilization management.
- Experience reviewing medical necessity criteria and healthcare benefits.
- Bachelor’s degree in Nursing, Healthcare Administration, or a related healthcare field preferred; equivalent specialized training, certification, or relevant professional experience may be considered in lieu of a degree.
Responsibilities
- Conduct utilization reviews and clinical assessments to evaluate the medical necessity, appropriateness, and efficiency of healthcare services.
- Apply evidence-based criteria and clinical expertise to support benefit and utilization management decisions.
- Review medical records, treatment plans, and supporting documentation for compliance with clinical guidelines, organizational policies, and regulatory requirements.
- Develop, coordinate, and support care plans with healthcare providers, multidisciplinary teams, and payers.
- Prepare, audit, and manage approval and denial letters in accordance with established policies and regulatory standards.
- Promote effective utilization management practices through consultation, education, and collaboration with healthcare professionals and stakeholders.
- Support care coordination to improve member outcomes and ensure appropriate access to healthcare services.
- Communicate with providers, members, and internal teams about utilization management decisions and processes.
- Maintain complete, accurate, and timely documentation to meet risk management, regulatory, and accreditation requirements.
- Provide guidance and coaching to nursing staff and other healthcare professionals on utilization management principles and best practices.
- Contribute to the development and implementation of utilization management policies, procedures, and quality improvement initiatives.
- Promote the quality, effectiveness, and efficiency of healthcare services across the continuum of care.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources based on eligibility
- Potential eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
