Utilization Management Nurse Consultant

RN Utilization Management Nurse Consultant (Medicare – Joint Procedures)

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.

Are you an experienced Registered Nurse looking to make an impact beyond the bedside? Join a collaborative Utilization Management team where your clinical expertise helps ensure members receive the right care at the right time.

What You'll Do

• Review and assess clinical information for Medicare precertification (joint procedures)
• Apply evidence-based criteria and clinical judgment to make coverage determinations
• Collaborate with providers and care teams to coordinate appropriate treatment plans
• Identify opportunities to improve care quality and optimize healthcare utilization
• Support care integration by connecting members to additional programs and services
• Serve as a clinical resource to internal and external partners

What You Bring - REQUIRED

• Active, unrestricted RN license in the state of residence
• 3+ years of RN experience
• 1+ year of Med/Surg experience
• Proficiency in Microsoft Office (Outlook, Teams, Excel)
• Associates degree in nursing

Nice to Have

• Utilization Management or Prior Authorization experience
• Managed care and/or Medicare experience
• MedCompass or similar system experience
• Ambulatory surgery background
• BSN

Why Join Us?

• Consistent weekday schedule (with some flexibility for a 24/7 operation)
• Opportunity to use your clinical expertise in a non-bedside role
• Collaborative, mission-driven team focused on quality care

Work from Home Requirements:

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.

• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.

• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.

• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).

• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.

• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.

• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).

• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.

• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.

• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

$26.01 - $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.