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.

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.