Utilization Management Nurse Consultant

Job not on LinkedIn

🔥 2 hours ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $26 - $68 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Conduct utilization reviews and clinical assessments to evaluate medical necessity, appropriateness, and efficiency of healthcare services • Apply evidence-based criteria and clinical expertise to benefit and utilization management decisions • Review medical records, treatment plans, and supporting documentation for compliance with guidelines, policies, and regulatory requirements • Develop, coordinate, and support care plans with healthcare providers, multidisciplinary teams, and payers • Prepare, audit, and manage approval and denial letters • Promote utilization management practices through consultation, education, and collaboration • Support care coordination to improve member outcomes and access to healthcare services • Communicate with providers, members, and internal teams about utilization management decisions and processes • Maintain complete, accurate, and timely documentation • Provide guidance and coaching to nursing staff and healthcare professionals • Contribute to utilization management policies, procedures, and quality improvement initiatives • Promote quality, effectiveness, and efficiency of healthcare services across the continuum of care

🎯 Requirements

• Active Registered Nurse (RN) license • 3–5 years of relevant clinical, case management, utilization management, or healthcare experience • Knowledge of medical terminology and healthcare delivery systems • Strong problem-solving and critical-thinking skills • Effective decision-making abilities with demonstrated clinical judgment • Proficiency with technology and digital tools used in healthcare environments • Ability to analyze costs and benefits of alternative approaches and recommend appropriate solutions • Strong interpersonal and communication skills • Ability to maintain confidentiality and handle sensitive information ethically and responsibly • Ability to work effectively within diverse clinical and cultural environments • Availability to work Thursday–Sunday, 9:00 AM–8:00 PM Eastern Time • Experience in utilization management, care management, managed care, or health plan operations • Knowledge of regulatory, accreditation, and quality standards related to utilization management • Experience reviewing medical necessity criteria and healthcare benefits • Bachelor's degree in Nursing, Healthcare Administration, or a related healthcare field preferred • Equivalent specialized training, certification, or relevant professional experience may be considered in lieu of a degree

🏖️ Benefits

• 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 range (eligibility may apply)

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