Utilization Management Nurse Consultant

CVS Health; Clifton (TX); On-site; USD 40,000 - 86,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is hiring a Medicare Clinical Predetermination Nurse in Utilization Management. This full-time role requires: Monday–Friday, 9:00am–5:30pm ET or CT with occasional holiday rotation; Utilization Management is a 24/7 operation with evening hours and holiday shifts.

You will apply clinical judgment to render coverage determinations, coordinate care, gather information, and communicate with providers to optimize member outcomes and appropriate services.

Qualifications

• ~3+ years of experience as a Registered Nurse.
• Active, current and unrestricted RN licensure in state of residence.
• ~1+ years of Med/Surg experience.
• ~1+ years of experience with Microsoft Office applications.
• ~ Must be willing to work Monday–Friday, 9:00am–5:30pm ET or CT; holidays and evening hours.

Responsibilities

• Utilizes clinical experience to assess, plan, implement, coordinate, monitor and evaluate options for appropriate healthcare services/benefits.
• Gathers clinical information and applies guidelines to render coverage determinations/recommendations.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other programs.
• Identifies opportunities to promote quality and effectiveness of healthcare services and benefit utilization.
• Consults with internal and external constituents in utilization/benefit management.

Skills

Registered Nurse experience

RN licensure active

Med/Surg experience

Microsoft Office

Work schedule evenings/holidays

Education

Associate degree

BSN preferred

Tools

Microsoft Office (Outlook, Teams, Excel)

Job description

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. Medicare Clinical Predetermination Nurse

Must be willing and able to work Monday through Friday, 9am - 5:30pm EST or CST with occasional holiday rotation.

Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours.

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 a Registered Nurse
• ~ Must have active current and unrestricted RN licensure in state of residence
• ~1+ years of Med/Surg experience
• ~1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
• ~ Must be willing and able to work Monday through Friday, 9:00am to 5:30pm eastern or central time with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

Preferred Qualifications

• Prior Authorization or Utilization Management experience
• Managed care experience
• Experience using MedCompass
• Ambulatory surgery experience

Education

• Associates degree required
• BSN preferred

Anticipated Weekly Hours

40 Time Type

Full time Pay Range

The typical pay range for this role is:

$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.

Additional details about available benefits are provided during the application process and on Benefits Moments .

We anticipate the application window for this opening will close on: 10/20/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.