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 license
• 3+ 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 experience
• 1+ 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 - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 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.

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We anticipate the…