Utilization Management (UM) Nurse Consultant - Work at Home in EST or CST Zone

Utilization Management (UM) 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.

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 or CST Zones. You'll apply your clinical expertise to ensure members receive safe, effective, and appropriate careat the right time and in the right setting.

Schedule:

• Mon Fri 8:00 Am 05:00 PM
• 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)

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

• 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:

$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 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.

Additional details about available benefits are provided during the application process and on Benefits Moments.