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Utilization Management Nurse Consultant
R0822977 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
- 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.
