Utilization Management Nurse Consultant

CVS Health Corporation; Northern (KY); Hybrid; USD 36,000 - 77,000; Full time

Job summary

CVS Health Corporation is seeking an experienced Registered Nurse for Utilization Management. The role examines and coordinates care options, applying clinical criteria to determine coverage and guide patient pathways.

The position operates in a 24/7 environment with weekends, holidays and evenings. Remote work is supported for colleagues who live in-state, with equipment provided and HIPAA-compliant home offices, within a competitive pay and benefits package.

Qualifications

• 2+ years of experience as a Registered Nurse in adult acute/critical care.
• Active, unrestricted RN licensure in state of residence.
• Willingness to work weekends, holidays, and evenings.

Responsibilities

• Assess, plan, implement, coordinate and monitor care options for members.
• Render coverage determinations using guidelines and clinical judgment.
• Communicate with providers to facilitate treatment and care transitions.
• Identify referral opportunities to integrate with programs and services.

Skills

Clinical assessment

Education

RN license

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.

Position Summary

Utilization Management is a 24/7 operation and work schedules will include weekends, 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. Typical office working environment with productivity and quality expectations.

Required Qualifications

• 2+ years of experience as a Registered Nurse in adult acute care/critical care setting
• Must have active current and unrestricted RN licensure in state of residence
• Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours

Preferred Qualifications

• 2+ years of clinical experience required in med surg or specialty area
• Managed Care experience preferred, especially Utilization Management
• Preference for those residing in EST zones

Education Associates Degree required BSN preferred

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: 08/31/2026

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.