Utilization Management Nurse Consultant
About The Position
CVS Health is seeking an experienced Registered Nurse to join its Utilization Management team. The nurse uses clinical expertise to review cases, support coverage determinations, coordinate care, and help ensure members receive appropriate healthcare services across the continuum of care. The role reviews clinical information using evidence-based criteria, collaborates with providers and healthcare teams, identifies opportunities to improve quality and outcomes, connects members with additional programs and services, and serves as a clinical resource for stakeholders. This is a work-from-home position. The employee must work from the state and city where they have confirmed they currently live and maintain a quiet, secure, private, and HIPAA-compliant home workspace. A direct, hardwired internet connection to a modem or 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 work equipment, while the employee supplies workspace furniture. The position requires extended desk work and effective navigation of multiple monitors, applications, communication tools, and secure systems. The operation runs 24/7, and schedules may include evenings, weekends, and holidays. Anticipated hours are 40 per week. The position pays $26.01–$74.78 per hour. The actual offer depends on factors such as experience, education, and geography. The role may also be eligible for a bonus, commission, or short-term incentive program. Eligible full-time employees receive a benefits package that includes medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.
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.
- Strong communication, critical thinking, and multitasking skills.
- Proficiency navigating multiple computer systems.
- Associate degree in Nursing.
- Ability to meet the work-from-home requirements, including maintaining a qualifying wired internet connection and a quiet, secure, private, HIPAA-compliant workspace.
- Ability to work within the state and city where the employee has confirmed they currently live.
- 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, follow computer and password security practices, and recognize suspicious emails or links.
- Ability to troubleshoot common technical issues 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.
- Managed Care and/or Utilization Management experience.
- Residence in the Central or Eastern time zones.
- Bachelor of Science in Nursing (BSN).
Responsibilities
- Review clinical information and apply evidence-based criteria to make utilization and coverage recommendations.
- Collaborate with providers and healthcare teams to support appropriate treatment plans and care coordination.
- Identify opportunities to improve healthcare quality, outcomes, and benefit utilization.
- Refer members to additional 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 to support colleagues’ physical, emotional, and financial well-being, based on eligibility
- Potential 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
