Utilization Management N0urse Consultant - Work at Home

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.

Utilization Management Nurse Consultant

Location

Preference: EST and/or CST (will work in your residence time zone)

Work Schedule:

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours

Multiple Shifts available including: Mon-Fri 8-5, 11-8, Split Shifts, 4-10 hour Thur-Sun 7:00AM-05:30 PM

Position Summary

Responsible for reviewing and coordinating healthcare services to ensure members receive appropriate, high-quality, and cost-effective care. Uses clinical expertise to assess member needs, apply clinical guidelines and policies, and make coverage recommendations across the continuum of care. Collaborates with providers, care teams, and internal partners to support treatment planning, care coordination, and member outcomes. Identifies opportunities to improve healthcare quality, optimize benefit utilization, and connect members with additional programs and services when appropriate.

This position is primarily sedentary in a fast-paced office or work-from-home environment and requires strong multitasking, communication, computer navigation, and decision-making skills. Success in this role requires the ability to work across multiple systems, manage competing priorities, and effectively communicate with both internal and external stakeholders.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in the state of practice.
• Minimum of 2+ years of recent, progressive bedside clinical nursing experience in multiple healthcare specialties.
• Demonstrated hands-on clinical experience across several of the following areas: Medical-Surgical Nursing (Med-Surg) Orthopedics Cardiology/Cardiac Care Long-Term Care (LTC) Inpatient Rehabilitation Wound Care and Skin Integrity Management Skilled Nursing Facilities (SNF) Telemetry Post-Acute Care Acute Care Hospital Settings Case Management or Utilization Management

Skills Preferred

• Proven ability to assess, coordinate, and manage care for medically complex populations with multiple chronic conditions and co-morbidities.
• Strong clinical judgment with the ability to interpret medical records, treatment plans, medication regimens, diagnostic testing, and physician documentation.
• Experience collaborating with interdisciplinary teams, including physicians, therapists, behavioral health providers, social workers, and care coordinators.
• Comprehensive understanding of care transitions across acute, post-acute, rehabilitation, and long-term care settings.
• Demonstrated expertise in identifying gaps in care, developing interventions, and improving member/patient outcomes.
• Excellent critical thinking, time management, and decision-making skills in fast-paced healthcare environments.
• Strong verbal and written communication skills with the ability to effectively engage members, caregivers, providers, and healthcare partners.
• Proficiency with electronic medical records (EMR/EHR) systems and Microsoft Office applications.

Preferred Qualifications

• Experience in Managed Care, Utilization Management, Care Management, Population Health, or Health Plan Operations.
• Experience supporting Medicare, Medicaid, Dual Eligible, LTSS, MLTSS, or complex care populations

Education Qualifications

• Associate Degree in Nursing (ADN)
• Bachelor of Science in Nursing (BSN) preferred
  

Required 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

Required - 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 50 Mbps download and 5 Mbps 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.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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

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