Utilization Management Nurse Consultant

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.

Utilization Management is a 24/7 operation and work schedule may include weekends, holidays, and evening hours.

Fully Remote- WFH

Schedule: Monday-Friday 8a-5p EST/9a-6p CST with 1 hour lunch

Position Summary

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

• 3+ years of experience as an RN
• Active and unrestricted RN licensure in state of residence
• Able to work in multiple IT platforms/systems
• 1+ years of experience with Microsoft Office Applications (Outlook, Teams, Excel)

Preferred Qualifications

• Prior authorization utilization experience preferred
• Outpatient Clinical experience
• Knowledge of Medicare/Medicaid
• Managed care experience

Education

• Associates Degree in Nursing required
• BSN preferred

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: $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.