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Utilization Management Nurse Consultant
CVS HealthNurse Consultant applying clinical judgment and evidence-based criteria for Utilization Management at CVS Health. Collaborating with providers and maintaining accurate documentation in a remote role.
About the role
Key responsibilities & impact- Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review.
- Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information.
- Use established guidelines to authorize services or escalate to Medical Directors as needed.
- Navigate multiple computer systems efficiently while maintaining accurate documentation.
- Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills.
- Ensure continuity of care and operational support as a Utilization Management (UM) Nurse across various UM specialty teams as needed.
- Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.
Requirements
What you’ll need- Active unrestricted state Registered Nurse licensure in state of residence required.
- Minimum 5 years of relevant experience in Nursing.
- At least 1 year of Utilization Management experience in concurrent review or prior authorization.
- Strong decision-making skills and clinical judgment in independent scenarios.
- Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms.
- Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.
Benefits
Comp & perks- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewprecertificationconcurrent reviewdecision-makingclinical judgmentnursing
Soft Skills
critical thinkingorganizational skillsmultitaskingprioritizationcollaboration
Certifications
Registered Nurse licensure