Utilization Management Nurse Consultant - Work at Home - Eastern Standard Hours

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. • Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. • Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. • Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function • Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care. • Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support). • Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment. • Identifies members who may benefit from care management programs and facilitates referral • Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization • Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding required. Required Qualifications • 3+ years clinical practice experience as a Registered Nurse preferably in an acute setting (ex: OR, ER, ICU, med surg, home health, pediatrics, NICU, PICU) • Must have current active and unrestricted RN licensure in state of residence • Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours. • 2+ years of experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.) Preferred Qualifications • Managed care experience • Utilization management experience • Pediatrics Experience • Resides in Pennsylvania Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $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. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 11/28/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job