RN Utilization Management Consultant: Optimize Care

ISHE; Idaho; On-site; USD 36,000 - 94,000; Full time

Job summary

CVS Health is seeking an Utilization Management Nurse to coordinate and manage healthcare services, review clinical information, determine medical necessity, and ensure regulatory compliance. This role emphasizes quality, cost-effective care, and accurate documentation while collaborating with healthcare providers, payers, and internal teams.

The position requires an active RN license, 3–5 years of related experience, strong problem-solving skills, and the ability to work a Thursday–Sunday

Qualifications

• Active RN license.
• 3–5 years of clinical, case management, utilization management, or healthcare experience.
• Knowledge of medical terminology and healthcare delivery systems.
• Strong problem-solving and critical-thinking skills.
• Proficiency with technology and digital tools used in healthcare environments.

Responsibilities

• Conduct utilization reviews and clinical assessments to evaluate medical necessity and efficiency.
• Apply evidence-based criteria to support benefit decisions.
• Review medical records and treatment plans for regulatory compliance.
• Develop and coordinate care plans with providers, multidisciplinary teams, and payers.
• Prepare and manage approval/denial letters per policies and standards.
• Promote utilization management through education and collaboration with professionals.
• Support care coordination to improve member outcomes and access to services.
• Communicate decisions with providers, members, and internal teams.
• Maintain complete, accurate, timely documentation for risk, regulatory and accreditation needs.
• Provide guidance to nursing staff on utilization management principles.

Skills

RN license

Clinical experience

Communication skills

Analytical thinking

Regulatory knowledge

Technology proficiency

Education

Bachelor's degree in Nursing

Job description

CVS Health is seeking an Utilization Management Nurse to coordinate and manage healthcare services, review clinical information, determine medical necessity, and ensure regulatory compliance. This role emphasizes quality, cost-effective care, and accurate documentation while collaborating with healthcare providers, payers, and internal teams.

The position requires an active RN license, 3–5 years of related experience, strong problem-solving skills, and the ability to work a Thursday–Sunday