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 Join a dynamic healthcare team and make an impact on patient care from wherever you work. We are seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will use your clinical expertise to review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services.

Review clinical information and apply evidence-based criteria to support coverage determinations and care recommendations. Collaborate with providers, care teams, and internal partners to coordinate treatment and services. Identify opportunities to improve healthcare quality, outcomes, and benefit utilization. Refer members to appropriate programs and services that support their overall health needs. Serve as a clinical resource for utilization and benefit management questions.

Required Qualifications Active, unrestricted RN license in your state of residence. 2+ years of RN experience in an adult acute care or critical care setting. Associate Degree in Nursing. Strong communication, multitasking, and computer navigation skills. Ability to work a designated schedule of 8:00 am to 5:00 P M ET , including weekends, holidays, and evening hours based on business needs.

BSN preferred. Clinical experience in Med-Surg or a specialty area. Managed Care and/or Utilization Management experience. Candidates located in the Eastern Time Zone preferred. Why Join Us? Apply your clinical expertise in a collaborative, fast-paced environment. Help improve healthcare outcomes for members across the continuum of care. Work with a mission-driven team focused on quality, efficiency, and patient-centered care. Ready to leverage your nursing experience in a rewarding Utilization Management role? 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 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