Utilization Management Nurse Consultant

4062 Aetna Resources, LLC; Indiana (PA); Hybrid; USD 54,000 - 117,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking an experienced Registered Nurse (RN) for Utilization Management in a remote, work-from-home role within our 24/7 operations. You will review clinical documentation, coordinate care, and collaborate with care teams to ensure high-quality, cost-effective services.

The role requires an active RN license in your state, 2+ years of adult acute/critical care experience, and strong assessment and communication skills. BSN preferred but not required; associate degree required.

Qualifications

• Active RN license in residence state.
• 2+ years of adult acute and/or critical care nursing experience.
• Strong clinical assessment and communication skills.
• Ability to manage multiple priorities in a fast-paced, tech-driven environment.
• Proficiency navigating multiple computer systems.
• Associate Degree in Nursing required.

Responsibilities

• Review clinical documentation and apply criteria to support coverage determinations.
• Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care.
• Collaborate with providers and care teams to facilitate treatment plans and care coordination.
• Identify opportunities to improve healthcare quality and utilization.
• Connect members to additional programs and resources that support outcomes.
• Serve as a clinical resource to internal and external stakeholders.

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.

Registered Nurse (RN) – Utilization Management Remote | Work from Home | 24/7 Operations

Are you an experienced RN looking to transition from bedside care while continuing to make a meaningful impact on patient outcomes? Join our Utilization Management team and use your clinical expertise to help ensure members receive appropriate, high-quality, and cost-effective healthcare services.

What You'll Do

• Review clinical documentation and apply evidence-based criteria, policies, and clinical judgment to support coverage determinations
• Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care
• Collaborate with providers and care teams to facilitate appropriate treatment plans and care coordination
• Identify opportunities to improve healthcare quality, effectiveness, and benefit utilization
• Connect members to additional programs and resources that support positive health outcomes
• Serve as a clinical resource and consultant to internal and external stakeholders

WHAT YOU BRING - REQUIRED

• Active, unrestricted RN license in your state of residence
• 2+ years of adult acute care and/or critical care nursing experience
• Strong clinical assessment, critical thinking, and communication skills
• Ability to manage multiple priorities in a fast-paced, technology-driven environment
• Proficiency navigating multiple computer systems
• Associate Degree in Nursing required

Preferred Qualifications

• 2+ years of Med-Surg or specialty nursing experience
• Managed Care or Utilization Management experience
• Residence in the North Central Time Zone preferred
• BSN preferred

Schedule & Work Environment

Utilization Management is a 24/7 operation Schedules may include evenings, weekends, and holidays Computer-based role with productivity and quality expectations Frequent collaboration with providers, members, and interdisciplinary teams

Why Join Us?

Apply your clinical expertise in a rewarding non-bedside nursing role. Help improve healthcare quality and member outcomes. Work remotely while collaborating with an experienced clinical team. Build valuable experience in Utilization Management and Managed Care.

If you're an RN who enjoys clinical decision-making, care coordination, and making a difference at a broader level, we'd love to hear from you.

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 technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.

Future Growth:

Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $26.01 - $56.14 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: 10/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.