Utilization Management Nurse Consultant

Job Description:

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary
This is a fully remote role open to candidates with an active RN licensure in the state in which they reside.

Working schedule is Monday-Friday, 8am-5pm with rotating weekends and holidays required. This is a typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of and written and computer-generated documents as well as a PC monitor. Position involves sedentary work involving periods of sitting, talking, and listening. Work requires sitting for extended periods of time, talking on the telephone, and typing on the computer.

The UM Nurse Consultant utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidencebased care and medical necessity criteria for appropriate utilization of services.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support).
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs and facilitates referral
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Required Qualifications

• Active and unrestricted RN licensure in the state of residence
• Willingness to obtain additional licensure upon hire - paid for by the company
• 3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care

Preferred Qualifications

• NICU experience highly preferred
• Managed care/utilization review experience
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Proficiency with personal computers, keyboard, and multi-systems navigation, and MS Office Suite applications

Education

• Associate degree or diploma in Nursing required
• Bachelor of Science in Nursing preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $74.78

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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/01/2025

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