Utilization Management Nurse Consultant
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Job Description
Utilization management nurse reviewing clinical cases and making evidence-based coverage decisions for CVS Health members. Coordinating treatment with providers and improving care quality remotely.
Responsibilities:
- Review clinical cases and make coverage determinations using evidence-based guidelines
- Collaborate with providers and care teams to coordinate appropriate treatment
- Apply clinical judgment to utilization and benefit management decisions
- Identify opportunities to improve care quality and member outcomes
- Serve as a clinical resource across internal and external stakeholders
- Use clinical expertise in a collaborative, non-bedside role focused on care coordination and healthcare quality
Requirements:
- Active, unrestricted RN license in the state of residence
- 3+ years of RN experience, including 1+ year in Med/Surg
- Strong clinical assessment and decision-making skills
- Experience with Microsoft Office (Outlook, Teams, Excel)
- Ability to work Monday–Friday, 9:00 AM–5:30 PM in your time zone
- Work schedules may include holidays and evening hours because Utilization Management is a 24/7 operation
- Associate Degree in Nursing
- Direct/hardwired internet connection to a modem/router within 7 feet of the computer
- Minimum internet speed of 25 Mbps download and 3 Mbps upload
- WiFi and satellite internet are not permitted
- Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently living
- Must provide workspace furniture, such as a desk or standing desk
- Microsoft Office 365 applications or similar Google Workspace experience
- Ability to navigate multiple monitors and applications simultaneously
- Ability to use email, calendar invites, Teams messaging, and virtual meetings
- Ability to log in to secure systems such as VPN and EHR portals
- Ability to follow computer security practices, manage strong passwords, and recognize suspicious emails or links
- Ability to troubleshoot common technical issues independently
- Openness to learning new skills as the workplace evolves
- Utilization Management or Prior Authorization experience, managed care background, familiarity with MedCompass, ambulatory surgery experience, and BSN are nice to have/preferred
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
- Supportive, team-driven environment
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