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. Utilization Management Nurse Consultant (RN) Join a team that makes a difference in healthcare outcomes. We are seeking an experienced Registered Nurse (RN) to support our Utilization Management team in a fast-paced, collaborative environment. In this role, you will leverage your clinical expertise to review healthcare services, assess medical necessity, coordinate care, and ensure members receive appropriate, high-quality healthcare benefits.

Review clinical information and apply evidence-based criteria to make coverage recommendations. Collaborate with providers and interdisciplinary teams to support member care. Identify opportunities to improve healthcare quality, outcomes, and benefit utilization. Coordinate referrals to additional programs and services that support member needs. Serve as a clinical resource for internal and external stakeholders. What We're Looking For - REQUIRED Active, unrestricted RN license in your state of residence. 2+ years of RN experience in adult acute care, critical care, medical-surgical, or specialty settings. Strong clinical judgment, communication, and multitasking skills. Ability to work efficiently across multiple computer systems in a productivity-driven environment. Associate’s Degree in Nursing Preferred Qualifications 2+ years of clinical experience as a Registered Nurse in Adult acute care/critical care nursing Utilization Management or Managed Care experience. Residence in the Eastern Time Zone preferred. BSN Schedule This is a 24/7 operation , and schedules may include evenings, weekends, and holidays . If you're a clinically strong RN who enjoys combining patient advocacy, care coordination, and healthcare decision support, we'd love to hear from you. Apply today and help ensure members receive the right care at the right time. 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