Utilization Management Nurse Consultant
About The Position
CVS Health is seeking an experienced Registered Nurse to join its Utilization Management team in a remote role. The nurse uses clinical expertise to review and coordinate care, determine whether healthcare services are appropriate, and help members achieve positive outcomes. The position involves applying evidence-based criteria to coverage determinations, collaborating with providers and care teams, identifying care coordination and referral opportunities, and documenting decisions while meeting productivity and quality goals. The team operates 24/7, and schedules may include evenings, weekends, and holidays. The role is remote, subject to work-from-home requirements. The employee must work from the state and city where they have confirmed residence and maintain a quiet, secure, private home workspace compliant with company and HIPAA guidelines. A wired internet connection meeting specified speed requirements is required; Wi-Fi and satellite internet are not permitted. The company provides work equipment, while the employee provides workspace furniture. The position requires extended desk work, comfort with multiple monitors and applications, use of digital communication and collaboration tools, secure system access, and basic technical troubleshooting.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 2 years of RN experience in adult acute care, critical care, med-surg, or a specialty area.
- Associate Degree in Nursing.
- Ability to meet the work-from-home requirements, including a direct wired internet connection with at least 25 Mbps download and 3 Mbps upload, and a quiet, secure, private designated workspace.
- Comfort with setting up and using multiple monitors and navigating multiple applications simultaneously.
- Ability to communicate through email, calendar invitations, Teams messaging, and virtual meetings.
- Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
- Ability to access secure systems, follow security practices, troubleshoot common technical issues, and learn new skills as the workplace evolves.
Nice To Haves
- Utilization Management or Managed Care experience.
- Bachelor of Science in Nursing (BSN).
- Strong clinical assessment, communication, and critical thinking skills.
- Ability to multitask and thrive in a technology-driven environment.
- Residence in the Eastern Time Zone.
Responsibilities
- Review clinical information and apply evidence-based criteria to coverage determinations.
- Collaborate with providers, care teams, and internal partners to support quality patient care.
- Identify opportunities for care coordination and program referrals.
- Promote effective healthcare utilization and positive member outcomes.
- Document decisions and navigate multiple systems while meeting productivity and quality goals.
Benefits
- Medical coverage.
- Dental coverage.
- Vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Other resources, based on eligibility.
- 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
Education Level
Associate degree
