Utilization Management Nurse Consultant - Must reside in Florida

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.

Position Summary

Utilization Management Nurse Consultant - must reside in Florida

Work from home anywhere in Florida. Candidates must reside in Florida.

As a Utilization Management Nurse Consultant, you will leverage your clinical expertise to review, coordinate, and manage healthcare services for members, ensuring the right care is delivered at the right time and in the most appropriate setting. This role involves evaluating clinical information, applying evidence-based guidelines and medical necessity criteria, and collaborating with providers and interdisciplinary teams to support quality, cost-effective healthcare outcomes.

Please Note: Utilization Management is a 24/7 operation. Schedules may include evenings, weekends, and holidays.

Key Responsibilities

Review clinical documentation and apply medical necessity criteria, policies, and clinical guidelines to make coverage determinations and recommendations.

Coordinate and communicate all aspects of utilization and benefit management activities across the continuum of care.

Collaborate with providers, healthcare teams, and internal stakeholders to facilitate appropriate treatment plans, discharge planning, and care transitions.

Utilize critical thinking and clinical judgment to support evidence-based care and appropriate resource utilization.

Identify members who may benefit from care management programs and facilitate referrals as appropriate.

Support urgent and emergent member needs, including triage and crisis intervention when necessary.

Serve as a clinical resource and consultant for internal and external partners regarding utilization management processes and decisions.

Promote quality improvement initiatives and identify opportunities to enhance healthcare outcomes and benefit utilization.

Required Qualifications

Active, unrestricted Registered Nurse (RN) license in the state of Florida.

Minimum of 3 years of recent inpatient clinical nursing experience.

Ability and willingness to obtain additional state nursing licenses as needed (company-sponsored).

Must permanently reside in Florida.

Strong clinical assessment, documentation, communication, and critical-thinking skills.

Preferred Qualifications

Previous Utilization Management (UM) experience.

Managed Care experience.

Discharge planning and care coordination experience.

Experience applying medical necessity guidelines and utilization review criteria.

Education

Associate Degree in Nursing (ADN) required.

Bachelor of Science in Nursing (BSN) preferred.

$29.10 - $62.32

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.