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. Registered Nurse (RN) – Utilization Management Remote | Work from Home | 24/7 Operations Are you an experienced Registered Nurse looking to apply your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care at the right time through evidence-based clinical review and care coordination.
Requirements
- Active, unrestricted RN license in your state of residence
- 2+ years of adult acute care and/or critical care nursing experience
- Strong clinical assessment, critical thinking, and communication skills
- Ability to multitask and thrive in a fast-paced environment
- Proficiency navigating multiple computer systems and applications
- Associate Degree in Nursing required
- You must have or be able to obtain a 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.
- Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
- Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
- Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
- Systems Access & Security: 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.
- Troubleshooting & Support: 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.
- Future Growth: Openness to learning new skills in the future as the workplace environment evolves.
Nice To Haves
- 2+ years of Med-Surg or specialty nursing experience
- Managed Care or Utilization Management experience
- Residence in a Central Time Zone preferred
- BSN preferred
Responsibilities
- Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations
- Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care
- Collaborate with providers and care teams to facilitate appropriate treatment and care planning
- Identify opportunities to improve quality of care, health outcomes, and benefit utilization
- Connect members with additional programs and resources that support their healthcare 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
