Utilization Management Nurse Consultant
About The Position
CVS Health is seeking an experienced Registered Nurse for its Utilization Management team. The role uses clinical expertise to help ensure members receive appropriate care and resources throughout their healthcare journey. This is a computer-based, work-from-home position involving clinical review, healthcare decision-making, and collaboration with physicians, providers, interdisciplinary teams, and other stakeholders. The Utilization Management operation runs 24/7, so schedules may include evenings, weekends, and holidays. Work-from-home colleagues must work from the state and city where they have confirmed they currently live. The home work location must be quiet, secure, private, organized, compliant with CVS Health and HIPAA guidelines, and suitable for uninterrupted work. A direct, hardwired internet connection to a modem/router within seven feet of the computer is required, with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides computer equipment, while colleagues provide their own workspace furniture. The role requires working at a desk for extended periods and navigating multiple systems and documentation platforms.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 2 years of Registered Nurse experience in an adult acute care or critical care setting.
- Associate Degree in Nursing (ADN).
- Ability to meet the work-from-home requirements, including a direct hardwired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload.
- Ability to work from the state and city where the colleague has confirmed they currently live.
- Comfort using multiple monitors and navigating multiple applications simultaneously.
- Ability to communicate through 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, follow computer and password security practices, and recognize suspicious emails or links.
- Ability to troubleshoot common technical issues independently and contact IT when needed.
- Strong multitasking and communication skills.
Nice To Haves
- At least 2 years of Med-Surg or specialty clinical experience.
- Utilization Management or Managed Care experience.
- Bachelor of Science in Nursing (BSN).
- Location in the Eastern Time Zone is strongly preferred.
Responsibilities
- Review clinical information and apply evidence-based criteria to make coverage and authorization determinations.
- Collaborate with physicians, providers, and interdisciplinary teams to support quality patient outcomes.
- Identify opportunities for care coordination, case management, and other healthcare programs.
- Promote effective healthcare utilization and member-centered care.
- Serve as a clinical resource and partner for internal and external stakeholders.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- CVS Health bonus, commission, or short-term incentive program eligibility
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
