Utilization Management Nurse Consultant

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 is a 24/7 operation and work schedule may include weekends, holidays, and evening hours.

UM Nurse Consultant Fully Remote- WFH. Standard

Schedule:

4x10's - Thursday
- Sunday, 7A-5:30P in time zone (EST/CST). Training

Schedule:

Monday
- Friday 8A-5P in time zone (approx. 16 weeks).

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• 3+ years of experience as an RN in acute care/critical care setting
• Active and unrestricted RN licensure in state of residence
• Able to work in multiple IT platforms/systems
• 1+ years of experience with Microsoft Office Applications (Outlook, Teams, Excel)

• Prior authorization utilization experience preferred
• Outpatient Clinical experience
• Knowledge of Medicare/Medicaid
• Managed care experience

• Associates Degree in Nursing required
• BSN preferred

• 40

• Full time

The Typical Pay Range For This Role Is $26.01 - $68.55. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit

We anticipate the application window for this opening will close on: 02/28/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.