Utilization Management Nurse Consultant

CVS Health; Ohio; Hybrid; USD 40,000 - 86,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Job summary

CVS Health is seeking an experienced Registered Nurse to join our Utilization Management team in a remote capacity. The role focuses on ensuring members receive appropriate, high-quality services across the continuum of care.

The ideal candidate will have an unrestricted RN license, 2+ years in adult acute or critical care, and experience in managed care/utilization management. A BSN is preferred and a strong workflow with HIPAA compliance is required.

Qualifications

• Active, unrestricted RN license in your state of residence.
• 2+ years of RN experience in adult acute care or critical care settings.
• 2+ years of Managed Care and/or Utilization Management experience
• Education Associate Degree in Nursing required; BSN preferred.

Responsibilities

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

Skills

RN license

Clinical assessment

Utilization management

Communication

Multitasking

Tech-savvy

Education

Associate Degree in Nursing

BSN preferred

Tools

Microsoft Office 365

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 Location: Remote (Preference for candidates in CST or EST time zones) Schedule: 24/7 operation requiring flexibility for evenings, weekends, and holidays

Are you an experienced RN looking to leverage your clinical expertise in a dynamic, collaborative environment? Join our Utilization Management team and play a critical role in ensuring members receive appropriate, high-quality healthcare services.

What You'll Do

• 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.
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written

What We're Looking For

• Active, unrestricted RN license in your state of residence
• 2+ years of RN experience in adult acute care or critical care settings
• Strong clinical assessment, communication, and multitasking skills
• Comfortable working in a fast-paced, technology-driven environment
• 2+ years of Med-Surg or specialty clinical experience
• Managed Care and/or Utilization Management experience
• BSN preferred
• Education Associate Degree in Nursing 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

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.

Benefits

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: 11/07/2026

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.