Utilization Management Nurse Consultant
About The Position
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. Utilization Management Nurse Consultant (RN) Join a team that makes a difference in healthcare outcomes. We are seeking an experienced Registered Nurse (RN) to support our Utilization Management team in a fast-paced, collaborative environment. In this role, you will leverage your clinical expertise to review healthcare services, assess medical necessity, coordinate care, and ensure members receive appropriate, high-quality healthcare benefits.
Requirements
- Active, unrestricted RN license in your state of residence.
- 2+ years of RN experience in adult acute care, critical care, medical-surgical, or specialty settings.
- Strong clinical judgment, communication, and multitasking skills.
- Ability to work efficiently across multiple computer systems in a productivity-driven environment.
- Associate’s Degree in Nursing
- 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.
- Ability to work at your desk for extended periods of time.
- Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
- Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
- Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
- 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.
- 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.
- Openness to learning new skills in the future as the workplace environment evolves.
Nice To Haves
- Utilization Management or Managed Care experience.
- Residence in the Eastern Time Zone preferred.
- BSN
Responsibilities
- Review clinical information and apply evidence-based criteria to make coverage recommendations.
- Collaborate with providers and interdisciplinary teams to support member care.
- Identify opportunities to improve healthcare quality, outcomes, and benefit utilization.
- Coordinate referrals to additional programs and services that support member needs.
- Serve as a clinical resource for internal and external stakeholders.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
- 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
Education Level
Associate degree
