Utilization Management 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. Registered Nurse (RN) – Utilization Management Remote | Work from Home | 24/7 Operations Are you an experienced RN looking to transition from bedside care while continuing to make a meaningful impact on patient outcomes? Join our Utilization Management team and use your clinical expertise to help ensure members receive appropriate, high-quality, and cost-effective healthcare services.

Review clinical documentation and apply evidence-based criteria, policies, and clinical judgment to support coverage determinations Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care Collaborate with providers and care teams to facilitate appropriate treatment plans and care coordination Identify opportunities to improve healthcare quality, effectiveness, and benefit utilization Connect members to additional programs and resources that support positive health outcomes Serve as a clinical resource and consultant to internal and external stakeholders WHAT YOU BRING - REQUIRED Active, unrestricted RN license in your state of residence 2+ years of adult acute care and/or critical care nursing experience Strong clinical assessment, critical thinking, and communication skills Ability to manage multiple priorities in a fast-paced, technology-driven environment Proficiency navigating multiple computer systems Associate Degree in Nursing required Preferred Qualifications 2+ years of Med-Surg or specialty nursing experience Managed Care or Utilization Management experience Residence in the North Central Time Zone preferred BSN preferred Schedule & Work Environment Utilization Management is a 24/7 operation Schedules may include evenings, weekends, and holidays Computer-based role with productivity and quality expectations Frequent collaboration with providers, members, and interdisciplinary teams Why Join Us? Apply your clinical expertise in a rewarding non-bedside nursing role Help improve healthcare quality and member outcomes Work remotely while collaborating with an experienced clinical team Build valuable experience in Utilization Management and Managed Care If you're an RN who enjoys clinical decision-making, care coordination, and making a difference at a broader level, we'd love to hear from you. Apply today! 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