Utilization Management Nurse Consultant, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Nursing

Contract Type:
Employment contract

Salary:

26.01 - 62.32 USD / Hour

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Job Description:

Medicare Precertification Utilization Management Nurse Consultant position. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours. Position involves facilitating appropriate healthcare services/benefits for members through clinical assessment and coordination.

Job Responsibility:

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

Requirements:

3+ years of experience as a Registered Nurse
Must have active current and unrestricted RN licensure in state of residence
1+ years of Med/Surg experience
1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
Must be willing and able to work Friday, Saturday, Sunday and Monday 10 hr shifts after approx 4-5 months of training Monday - Friday 8:30-5pm EST with occasional holiday rotation
Associates degree required

Nice to have:

Prior Authorization or Utilization Management experience
Managed care experience
Experience using MedCompass
Ambulatory surgery experience
Medicare experience
BSN preferred

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
September 26, 2025

Expiration:
October 01, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Utilization Management Nurse Consultant