Utilization Management Nurse Consultant

CVS Health; Idaho; Hybrid; USD 36,000 - 94,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant to coordinate, document and communicate all aspects of the utilization/benefit management program. You will ensure the member receives appropriate care at the right time and place, while adhering to federal and state turnaround times and reviewing clinical records.

This full-time, remote role requires Monday–Friday 8:00am–4:30pm EST and offers comprehensive benefits, eligibility for bonus programs, and opportunities to support

Qualifications

• Active RN licensure in state of residence.
• Available to work Monday–Friday 8:00am–4:30pm EST.
• Willing to work weekend rotation about every 6 weeks.
• Holiday rotation per department need (typically 1 holiday per year).
• 3+ years of clinical RN experience.
• 1+ years experience using Microsoft Office Suite (Teams, Outlook, Word, Excel).
• Preferred: 1+ years Utilization Review or Managed Care experience.
• Must be able to coordinate, document and communicate utilization/benefit management activities.

Responsibilities

• Reviews services to assure medical necessity and appropriate benefit utilization.
• Coordinates, documents and communicates all aspects of utilization/benefit management.
• Assesses, plans, implements and coordinates options to facilitate appropriate healthcare services.
• Gathers clinical information and applies criteria to render coverage determinations.
• Communicates with providers and other parties to facilitate care/treatment.
• Identifies members for referral opportunities to integrate with other programs.
• Promotes quality effectiveness of healthcare services and benefit utilization.
• Lends expertise to internal and external stakeholders in utilization/benefit management.

Skills

Strong communication skills

Education

Associate degree

BSN

Tools

Microsoft Office Suite (Teams, Outlook, Word, 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.

Fully remote with requirement to work the following schedule:

Monday-Friday 8:00am-4:30pm EST.

Position Summary

As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.

The UM Nurse Consultant job duties include (not all encompassing):

• Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• 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

• Must have active, current, and unrestricted RN licensure in state of residence
• Must be available to work Monday through Friday 8:00am - 4:30pm EST
• Must be willing to work weekend rotation, approximately every 6 weeks
• Holiday rotation per the need of the department (typically 1 holiday per year)
• 3+ years of clinical RN experience
• 1+ years of experience using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications

• 1+ years' experience Utilization Review experience
• 1+ years' experience Managed Care
• Strong communication skills
• Ability to manage multiple priorities, effective organizational and time management skills required
• Experience in healthcare utilization management, critical care, emergency department, or case management

Education

Associate degree required

BSN preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $68.55

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.

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: 08/31/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.