Utilization Management Nurse Consultant

CVS Health

Utilization Management Nurse Consultant reviewing coverage decisions and coordinating healthcare services for CVS Health members. Applying clinical expertise remotely in Pennsylvania’s home-based 24/7 operations.

Posted 8/11/2026full-timeRemote • Pennsylvania • 🇺🇸 United StatesJuniorMid-Level💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates strong clinical assessment and decision-making skills while effectively coordinating and evaluating healthcare services. Proficient in navigating multiple computer systems and applications to enhance healthcare utilization and quality.

Highest-signal resume keywords

Active RN License2+ Years Adult Acute Care ExperienceClinical Assessment SkillsMicrosoft Office 365 ProficiencyUtilization Management Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Critical Care NursingHealthcare CoordinationEvidence-Based Criteria ApplicationQuality ImprovementTechnical Issue Resolution

Soft Skills

Excellent Communication SkillsAbility to Manage Competing PrioritiesOpenness to Learning

Tools & Technologies

EHR PortalsVPNMultiple MonitorsSecure SystemsTeams Messaging

Certifications & Qualifications

Associate Degree in NursingBSN (Preferred)

Industry Keywords

Managed CareMed-Surg NursingHIPAA ComplianceHealthcare UtilizationContinuum of Care

About the role

Key responsibilities & impact

Review clinical information and apply evidence-based criteria to support coverage determinations
Assess, coordinate, monitor, and evaluate healthcare services across the continuum of care
Collaborate with providers and care teams to facilitate appropriate treatment plans
Identify opportunities to improve quality, efficiency, and healthcare utilization
Connect members to additional programs and services as appropriate
Serve as a clinical resource for internal and external stakeholders
Work afternoon/evening shifts as part of 24/7 operations
Work approximately 40 hours per week
Navigate multiple monitors, applications, secure systems, and communication tools to perform work efficiently

Requirements

What you’ll need

Active, unrestricted RN license in your state of residence
2+ years of adult acute care and/or critical care nursing experience
Strong clinical assessment and decision-making skills
Ability to navigate multiple computer systems and manage competing priorities
Excellent verbal and written communication skills
Associate Degree in Nursing required
Willingness to work weekends, holidays, and evening shifts
Direct/hardwired internet connection to a modem/router within 7 feet of the computer, or ability to obtain one
Minimum internet speed of 25 Mbps download and 3 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
Ability to set up and use multiple monitors and navigate multiple applications simultaneously
Ability to communicate through email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace applications
Ability to log in to secure systems such as VPN and EHR portals
Ability to lock computer screens when unattended, manage strong passwords, and recognize suspicious emails or links
Ability to resolve common technical issues independently and contact IT when needed
Openness to learning new skills as the workplace evolves
Preferred: 2+ years of Med-Surg or specialty nursing experience
Preferred: Managed Care experience, particularly Utilization Management
Preferred: BSN
Preferred: Residence in the Eastern Time Zone

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to the base pay range
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting colleagues’ physical, emotional, and financial well-being
Company-provided equipment including keyboard, monitor, computer, and headset
Remote work from home
Comprehensive benefits package for full-time colleagues and their families