[Hiring] Utilization Management Nurse Consultant @CVS Health

Role Description

We’re looking for an experienced and compassionate Utilization Management (UM) Nurse Consultant to join our team. This is a fully remote role available to candidates in any U.S. state in the EST Zone. You’ll apply your clinical expertise to ensure members receive safe, effective care.

• Schedule: Monday – Friday 8:00 AM – 05:00 PM EST
• 10:00 AM – 07:00 PM shift required 1X a month (colleague can choose day)
• Includes weekends (12 per year)
• Includes Holidays (rotation 1 minor and 1 major per year)

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

• 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.

Qualifications

• Active, unrestricted RN license
• 2+ years of acute hospital clinical experience (strong preference for medical-surgical, ICU, behavioral health or other specialty area)
• 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: $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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources, based on eligibility

Application Information

We anticipate the application window for this opening will close on: 08/31/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.