Utilization Management Nurse Consultant

CVS Health; Mississippi; On-site; USD 40,000 - 86,000; Full time

Benefits offered by this job

Bonus program

Comprehensive benefits

Paid time off

Job summary

CVS Health in Mississippi is seeking a Medicare Clinical Predetermination Nurse to support utilization management efforts. This full-time role requires clinical RN expertise, coordination of care and collaborative decision-making to determine appropriate benefits and services for members.

You will work 40 hours weekly, be eligible for a comprehensive benefits package and bonus program; evening hours and holiday rotation are possible. BSN preferred, Associates degree required.

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 (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.

Responsibilities

• 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.

Skills

RN experience

Clinical assessment

Care coordination

Communication

Med/Surg experience

Microsoft Office

Education

Associates degree

BSN preferred

Tools

MedCompass

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, 9:00am - 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.

Responsibilities

• 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.