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 (UM) Nurse Consultant
100% Work‑From‑Home | Full-Time | Nationwide Opportunity We're looking for an experienced and compassionate Utilization Management (UM) Nurse Consultant to join our team. This is a work at home role and is available to candidates in any U.S. state. You'll apply your clinical expertise to ensure members receive safe, effective, and appropriate care-at the right time and in the right setting.

Schedule:

Monday-Friday, 8:00 AM-6:00 PM (in your local time zone)
Rotating Saturday shift as needed

No travel required

Position Summary As a UM Nurse Consultant, you will use your clinical background to coordinate, document, and communicate all aspects of the utilization and benefit management process. You'll ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times. This role involves reviewing clinical documentation, collaborating with providers, and supporting high-quality, cost‑effective care.

Key Responsibilities Your responsibilities will include (but are not limited to):

Reviewing services for medical necessity and appropriate benefit use, facilitating efficient discharge planning, and collaborating with providers and facilities to support members with complex needs.

Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.

Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations.

Communicating with providers and external partners to coordinate care and treatment plans.

Identifying opportunities for referrals to additional programs, services, or care solutions.

Recognizing opportunities to promote quality care delivery and effective benefit utilization.

Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.

Required Qualifications Candidates must meet the following requirements:

Active, unrestricted RN license3+ years of acute hospital clinical experience (strong preference for medical‑surgical or ICU; behavioral health-only acute experience is not eligible)
Strong clinical assessment and decision‑making abilities

Excellent organizational skills with the ability to manage multiple priorities

Ability to work independently and communicate effectively via phone

Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls

Preferred Qualifications 1+ year of Utilization Review experience1+ year of Managed Care experience

Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook)
Strong telephonic communication skills

Demonstrated ability to exercise sound judgment and collaborate with diverse teams

Education

Associate Degree in Nursing (ADN) required

Bachelor of Science in Nursing (BSN) preferred

Anticipated Weekly Hours
40

Time Type Full time

Pay Range The typical pay range for this role is:$29.10 - $62.32

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.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits -…