Utilization Management Nurse Consultant

CVS Health • Carolina, SC

5d • Remote

About The Position

CVS Health is seeking an experienced Registered Nurse to support its 24/7 Utilization Management team. The nurse uses acute-care experience and clinical judgment to review cases, assess medical necessity, coordinate care, and collaborate with providers to help members receive appropriate care and optimize healthcare outcomes. This is a work-from-home role, with requirements for a quiet, secure, private designated workspace and a direct wired internet connection meeting stated speed requirements. The company provides computer and related equipment; colleagues provide their own workspace furniture. The role involves using multiple monitors and applications, digital communication and collaboration tools, secure systems, and common technical troubleshooting. The position is full time, with 40 anticipated weekly hours, and offers a base pay range of $26.01–$74.78 per hour. It is also eligible for a CVS Health bonus, commission, or short-term incentive program.

Requirements

• Active, unrestricted RN license in the state of residence.
• At least 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.
• Ability to work a flexible schedule, including evenings, weekends, and holidays.
• Have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
• Maintain a quiet, secure, private designated home workspace that is free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allows uninterrupted work during work hours.
• Work from within the state and city where the employee has confirmed they currently live.
• Provide personal workspace furniture, such as a desk or standing desk, and be able to work at a desk for extended periods.
• Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
• Ability to communicate using digital channels such as email, calendar invites, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to access secure systems, lock an unattended computer screen, manage strong passwords, and recognize suspicious emails or links.
• Ability to resolve common technical issues independently and contact IT for unresolved issues.
• Openness to learning new skills as the workplace environment evolves.

Nice To Haves

• At least 2 years of Med-Surg or specialty clinical experience.
• Utilization Management and/or Managed Care experience.
• BSN preferred.
• Eastern Time Zone candidates preferred.

Responsibilities

• Review clinical information and apply evidence-based criteria to make coverage recommendations.
• Collaborate with providers and interdisciplinary teams to support care coordination.
• Identify opportunities to improve quality, outcomes, and healthcare resource utilization.
• Refer members to appropriate programs and services that support their healthcare needs.
• Serve as a clinical resource for internal and external stakeholders.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being, based on eligibility
• Eligibility for a CVS Health bonus, commission, or short-term incentive program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree