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Utilization Management Nurse Consultant – MST/PST Zone
CVS HealthCVS Health UM Nurse Consultant reviewing medical necessity and coordinating care for U.S. members.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and clinical assessment, with a strong focus on coordinating healthcare services and ensuring compliance with state and federal regulations. Proficient in collaborating with diverse teams and communicating effectively to support members with complex needs.
Highest-signal resume keywords
Active RN LicenseUtilization Review ExperienceManaged Care ExperienceClinical Assessment SkillsMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentDecision-MakingDischarge PlanningCare CoordinationCoverage DeterminationDocumentationMultitaskingJudgmentBenefit UtilizationHealthcare Services Evaluation
Soft Skills
Organizational SkillsEffective CommunicationCollaborationIndependenceSound Judgment
Certifications & Qualifications
Associate Degree in Nursing (ADN)Bachelor of Science in Nursing (BSN)
Industry Keywords
Medical NecessityUtilization ManagementAcute Hospital ExperienceBehavioral HealthICUMedical-SurgicalTelephonic CommunicationState and Federal RequirementsClinical GuidelinesHealthcare Benefits
About the role
Key responsibilities & impact- Review services for medical necessity and appropriate benefit use
- Facilitate efficient discharge planning
- Collaborate with providers and facilities to support members with complex needs
- Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits
- Collect and evaluate clinical information using clinical criteria, guidelines, policies, and judgment to make coverage determinations
- Communicate with providers and external partners to coordinate care and treatment plans
- Identify referrals to additional programs, services, or care solutions
- Promote quality care delivery and effective benefit utilization
- Serve as a resource to internal and external stakeholders on UM processes and clinical considerations
- Coordinate, document, and communicate utilization and benefit management activities while meeting state and federal requirements and turnaround times
Requirements
What you’ll need- Active, unrestricted RN license
- 2+ years of acute hospital clinical experience
- Strong preference for medical-surgical, ICU, behavioral health, or another specialty area
- Strong clinical assessment and decision-making abilities
- Excellent organizational skills and ability to manage multiple priorities
- Ability to work independently and communicate effectively by phone
- Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls
- 1+ year of Utilization Review experience preferred
- 1+ year of Managed Care experience preferred
- Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) preferred
- Strong telephonic communication skills preferred
- Demonstrated sound judgment and ability to collaborate with diverse teams
- Associate Degree in Nursing (ADN) required
- Bachelor of Science in Nursing (BSN) preferred
- Availability for Monday–Friday, 8:00 AM–5:00 PM CST
- Weekends (12 per year) and holidays (1 minor and 1 major per year) required
- One 1:00 PM–7:00 PM shift per month, with day selection
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- CVS Health bonus, commission or short-term incentive program in addition to base pay