Utiization 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.

Position Summary

This Utilization Management Nurse Consultant (UMNC) position is a work at home position (fully remote) and the candidate can live in any state.

Normal Working Hours: Monday through Friday 8:00am-4:30pm in the time zone of residence.

In addition, the team is open to candidates in PST and/or MST time zones to provide increased daily coverage until 6:30pm EST (10:00am-6:30pm EST).

There is a weekend (Saturday) and holiday rotation per the needs of the department.

Minimal travel is expected but could be up to 10% in the event of a clinical audit.

As a Utilization Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. Looking for someone who is high energy and motivated team environment and is detail oriented and highly organized. The UM Nurse Consultant reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• 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
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Required Qualifications

• Must have an active, current and unrestricted RN license in state of residence
• 2+ years of recent acute hospital clinical experience as an RN (recent defined as in the past 10 years)
• 1+ years of experience with Microsoft Office including PowerPoint, Excel, and Word
• Must be willing and able to work Monday through Friday 8:00am-4:30pm in the time zone of residence.

• Must be willing and able to work weekend and holiday rotation per the needs of the department

Preferred Qualifications

• Utilization Review experience
• Managed Care background
• Strong telephonic communication skills

Education

• Associates Degree in Nursing required
• Bachelor’s in Science & Nursing preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $56.14

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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